Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic lymphedema.
Treatment: Vascularized lymph node transfer (VLNT) and lymphaticovenous anastomosis.

The insurer denied coverage for VLNT and lymphaticovenous anastomosis.  The denial is upheld. 

This is a female patient with a history of chronic lymphedema. She presented to the vascular surgeon's office for a 4-month follow up visit after having a suction assisted protein lipectomy (SAPL) of the left leg. Her left leg was visibly smaller than her right leg.  There was a positive Stemmer's sign at the toes. The patient had sufficient pitting edema. The physician noted that the patient would benefit from conservative therapy and a lymphatic drainage procedure. He recommended a vascularized lymph node transfer and lymphaticovenous anastomosis to treat the patient's lymphedema.

This patient is being evaluated and treated for left leg lymphedema. This patient's lymphedema is believed secondary to Pelvic Desmoid surgery times 2. This is a review for both vascularized lymph node transfer and lymphaticovenous anastomosis.  

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. Based on current peer review literature the requested procedures are still considered as unproven. There is insufficient medical peer review literature to support the requested procedures for this patient's indication. 

As per Mehrara B, et al. 2021, "There is no consensus regarding the role of surgery, the optimal surgical approach, or the timing of an operative procedure for extremity lymphedema ..." 

Garza, R., 3rd, Skoracki, R., Hock, K., & Povoski, S. P. (2017), "Secondary lymphedema of the upper and lower extremities related to prior oncologic therapies, including cancer surgeries, radiation therapy, and chemotherapy, is a major cause of long-term morbidity in cancer patients ...It is hopeful that ongoing clinical research efforts will ultimately lead to more complete and sustainable treatment strategies and perhaps a cure for secondary lymphedema and its devastating resultant morbidities."      

Vascularized lymph node transfer (VLNT) and lymphaticovenous anastomosis to treat lymphedema (Codes: 38999 x3, 38900, 66990, 76499, 93971) is not Food and Drug Administration (FDA) regulated. This patient is not a good candidate for VLNT and lymphaticovenous anastomosis to treat lymphedema. The VLNT and lymphaticovenous anastomosis to treat lymphedema is not the best available treatment for this patient at this time.

While there are growing reports on the use of lymphedema surgery. These procedures are not known for overall improvement. There is no overall consensus in this country on the use of these surgical techniques to treat lymphedema. The American Society of Plastic Surgeons (ASPS) does not have a guideline or position statement with evidence-based recommendations for the treatment of lymphedema. They do address surgical options for lymphedema on the ASPS website. Furthermore, the submitted supporting article states more research is needed. Per Ozturk C, et al. (2016) VLNT appears to provide improvement in lymphedema. More studies with standardized method for reporting outcome and uniform patient selection are needed to evaluate this treatment thoroughly.     
  
The adverse risks are increased over standard treatment/service. As per Mehrara B, et al. (2021), "The most worrisome complication of VLNT is possible lymphedema from the donor site..."                                                    

The carrier's denial of coverage for a vascularized lymph node transfer and lymphaticovenous anastomosis to treat lymphedema (Codes: 38999 x3, 38900, 66990, 76499, 93971) should be upheld. The requested procedure is not likely to be more beneficial than any other standard health service.