Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lymphedema
Treatment: Suction assisted lipectomy debulking to treat lymphedema
The insurer denied suction assisted lipectomy debulking to treat lymphedema.
The determination is overturned.

This patient developed cellulitis of the legs and groin and a groin thrombus and was diagnosed with lymphedema. He had groin cellulitis with sepsis. A venogram was negative. He had scrotum reduction surgery complicated by an infection finally requiring penile skin grafting. A magnetic resonance imaging (MRI) scan showed normal veins and arteries in both legs and thigh to calf edema and fat hypertrophy worse on the right. A Lymphoscintigraphy of the legs at 1 hour showed no lymph nodes or lymphatic channels and ankle to knee back flow in the right leg and 1 inguinal node, dermal back flow at the medial knee and no lymphatic channels in the left leg. Manual lymphatic drainage, compression garments and pneumatic compression have not provided relief. Undated photos show the right leg is about 50% larger than the left with involvement of both ankles and feet. There are no open wounds, skin infections or skin lichenification visible.

An examination calculated leg volumes were 14830 cubic centimeters(cc) on the left and 19975 cc on the right. The volumes were 12768 cc on the left and 15975 cc on the right. Normal leg volumes are under 10,000 ml.

At issue is whether suction assisted lipectomy debulking to treat lymphedema is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The suction assisted lipectomy debulking to treat lymphedema is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The gold standard treatment for lymphedema is complex decongestive therapy (CDT). This includes manual lymphatic drainage, compression bandaging, exercise, skin care, and education in self-management techniques. Surgical treatment can be sectioned into debulking and physiologic procedures. Debulking procedures do not directly address lymphatic vessel dysfunction, but improve comfort by removing redundant skin and/or excess subcutaneous tissue. Physiologic procedures aim to restore lymphatic drainage by either directly anastomosing lymphatic collectors to veins or implanting healthy lymph nodes in the affected limb. There is no consensus on when the surgery should be offered. Circumferential suction-assisted lipectomy is an effective method for treating both primary and secondary lymphoedema of the leg with 100% reduction of the affected leg stable at 2 years. The preoperative volume difference between legs and the sex of the patient significantly influenced the final outcome after 2 years. Multiple medical journal publications have concluded that "Liposuction is a safe and effective option for carefully selected patients with advanced lymphedema".

Therefore, the proposed suction assisted lipectomy debulking to treat lymphedema is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease because it is effective and the patient's leg volumes have increased despite complex decongestive therapy.