Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for additional lipedema reduction surgeries consisting of suction-assisted lipectomy of the (1) circumferential torso; (2) calves/ankles/upper arms; and (3) circumferential thighs. Sandhofer and colleagues report that lipedema is believed to affect 11% to 39% of the female Caucasian population worldwide, and that as many as 16 million women in the United States may be affected with the disorder. Warren Peled and Kappos state, Lipedema is an uncommon disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The adiposity extends from hips to ankles and is typically unresponsive to weight loss. In addition to the aesthetic deformity, women also describe pain in the lower extremities, particularly with pressure, as well as easy bruising. Although the condition is well described, it is relatively rare and often misdiagnosed. The authors further note, Distinguishing lipedema from other conditions causing fatty excess in the lower extremities can be difficult. Making the diagnosis relies on some of the hallmark characteristics of lipedema, such as the easy bruising and pain with soft tissue pressure, as well as the step-off at the ankles. Women with generalized obesity typically do not have these history and physical exam characteristics. Additionally, although many patients with lipedema may also be overweight, those who have tried to lose weight through diet and exercise typically find that reducing the size of their legs is very challenging, which is often not the case in women with standard obesity. This distinction is less clear, however, in women who have localized adiposity in the lower extremities that is not due to lipedema. Similar to lipedema, localized adiposity in some areas of the legs, particularly the outer thighs, around the knees, and the lower calves, can be very resistant to diet and exercise in some women. Further, some women with lipedema may also have additional areas of localized adiposity, making the diagnosis even more challenging.Reich-Schupke and colleagues state, The diagnosis [of lipedema] is established on the basis of medical history and clinical findings. Characteristically, there is a localized, symmetrical increase in subcutaneous adipose tissue in arms and legs that is in marked disproportion to the trunk. Other findings include edema, easy bruising, and increased tenderness. Further diagnostic tests are usually reserved for special cases that require additional workup. Lipedema is a chronic, progressive disorder marked by the individual variability and unpredictability of its clinical course. The authors further note, Treatment consists of four therapeutic mainstays that should be combined as necessary and address current clinical symptoms: complex physical therapy (manual lymphatic drainage, compression therapy, exercise therapy, and skin care), liposuction and plastic surgery, diet, and physical activity, as well as psychotherapy if necessary. Surgical procedures are indicated if  despite thorough conservative treatment  symptoms persist, or if there is progression of clinical findings and/or symptoms. If present, morbid obesity should be therapeutically addressed prior to liposuction.In this case, the patient presents with severe obesity and persistent weight gain. The patient reports moderate pain in her upper and lower extremities, mild bruising, moderate thigh swelling when she stands for long hours, and difficulty driving, exercising, running, and commuting for long hours. Her symptoms are nonspecific, appear largely related to her severe obesity, and are not diagnostic of clinically significant lipedema. Photographs did not demonstrate ankle cuffing and showed evidence of exogenous obesity without evidence of disproportionate obesity. In this case, the submitted documentation reflects that the patient has severe exogenous obesity and does not support a diagnosis of clinically significant lipedema. Therefore, additional lipedema reduction surgeries consisting of suction-assisted lipectomy of the (1) circumferential torso; (2) calves/ankles/upper arms; and (3) circumferential thighs are not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the patient has exogenous obesity without evidence of clinically significant lipedema. Exogenous obesity is not an abnormal structure of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Thus, additional lipedema reduction surgeries consisting of suction-assisted lipectomy of the (1) circumferential torso; (2) calves/ankles/upper arms; and (3) circumferential thighs are not reconstructive in nature for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.