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 overturned. 

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.

The patient underwent treatment of a pelvic tumor. This was resected surgically.  Since that time the patient has had persistent left leg swelling. This has been documented with lymphoscintigraphy to be associated with poor lymphatic drainage. Two decades of conservative therapy have provided very little relief. Symptoms are documented to impact the patient's activities of daily living, including her livelihood. There has been some modest relief following suction-assisted protein lipectomy surgery. Her treating physician now proposes to perform vascularized lymph node transfer with venous anastomosis.  

The comprehensive reviews document there is scientific evidence in peer-reviewed literature that support a result of improvement and health outcome.

According to Grunherz et. al. (2020), "A significant improvement in the QOL (quality-of-life) in patients with LLL (lower limb lymphedema) after reconstructive lymph surgery can be observed."

According to Coriddi et. al. (2020), "Physiologic surgical treatment of lymphedema results in improved QOL (Quality of life) outcomes in most patients."

Scaglioni et at al. concluded (2018), "Vascularized lymph node transfer for lymphedema treatment is a promising operative technique showing beneficial results in early but also in advanced stage lymphedema. This physiologic surgical procedure should be included in a modern reconstructive concept for lymphedema treatment."      

Regulatory bodies do not certify or approve surgical procedures.     

The patient's symptoms have been refractory for nearly 20 years. The patient is young, with responsibility to care for family and motivation to participate in the employed workforce.  Appropriate medical treatment for her chronic condition, unrelieved by conservative therapy, is available. Her relative youth makes her an excellent candidate for the procedure.     

Vascularized lymph node transfer and lymphatic venous anastomosis to treat lymphedema is the best available treatment option for this patient at this time.  Alternative treatment options have failed to provide any relief. Scientific evidence supports the utility of the requested treatment.     
  
There certainly are risks associated with undergoing surgery compared to conservative treatments which do not involve surgery. These risks need to be included in a detailed informed consent process prior to the procedure. On balance, given that the patient symptoms have proven refractory to alternative treatments, and that her relative youth and fitness predict good tolerance of surgery, the risks are not greater than standard care. 

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.                                                    

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 overturned.