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.

The patient has bilateral lower extremity lymphedema of primary etiology. He has a significant history of infections. He was soon after diagnosed with a thrombus in his groin region. The patient was hospitalized for cellulitis in the groin region again, which then developed into a septic infection requiring a prolonged hospital stay. The patient had a third bout of cellulitis that started in the groin region, expanding to bilateral lower extremities, and proceeding to the development of a septic infection. The patient again was hospitalized for a prolonged period of time.

He underwent scrotal surgery for a persistently enlarged scrotum and underwent multiple subsequent surgeries after he developed a penile infection, including a skin graft, with now a significant improvement in the penile and scrotal swelling. He has bilateral lower extremity lymphedema. His lymphatic surgery workup consisted of magnetic resonance imaging (MRI) of the bilateral lower extremities, and Nuclear Medicine Lymphoscintigraphy of the bilateral lower extremities. On MRI, his right lower extremity presented with mild to moderate edema throughout and moderate fat hypertrophy in the upper thigh and calf.

The left lower extremity presented with subcutaneous edema throughout and mild fat hypertrophy circumferentially throughout the left leg. The Nuclear medicine Lymphoscintigraphy exam showed dermal backflow throughout both lower extremities which is indicative for impaired flow related to a lymphedema diagnosis.

To this date, he has been very compliant with his conservative therapy while being followed by the Lymphedema Therapy team. He spends 168 hours per week managing his disease with manual lymphatic drainage, compression bilaterally, exercises, and pneumatic devices.

At issue is whether 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 treatment is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The proposed surgery is medically necessary. The patient has functionally limiting lymphedema. He has minimal pitting edema, which indicates that he is a good candidate for liposuction to remove hypertrophied adipose tissue that accompanies chronic lymphedema. His lymphedema is disabling and treatment is time consuming. He has a history of infections. A study by Brorson, et al found that adipose tissue dominates chronic arm lymphedema, and therefore liposuction is a logical treatment to remove the hypertrophied fat associated with chronic lymphedema. Multiple studies confirm the efficacy of liposuction for patients with chronic limb enlargement due to lymphedema. A 5-year follow-up study by Schaverin, et al concluded, "Our first five years of experience of liposuction combined with application of compression garments has demonstrated significant, reproducible, and stable reduction of upper limb oedema with improvement of overall well-being and reduction in measurable anxiety and depression." According to a review by Erilymaz, et al, "Suction-assisted lipectomy offers patients with lower-extremity lymphedema a less invasive, less morbid surgical option compared with traditional excisional techniques." Case studies with more than 10 years of follow-up by Brorson, et al and Qi, et al confirm the long-term efficacy of liposuction for lymphedema. A 2006 study by Brorson, et al found that, "Liposuction plus chronic compressive therapy [CCT] improves patients' quality of life, particularly qualities related to the volume reduction and hence qualities associated with everyday activities. CCT is beneficial too, but the effect is less obvious than when combined with surgery, probably because the edema reduction is less." A 2015 review by Brorson concluded, "Improvements in techniques, patient preparation, and patient follow-up have led to a greater and wider acceptance of liposuction as a treatment for lymphedema in patients with large chronic nonpitting extremity lymphedemas." According to a study by Stewart and Munnoch: "We have demonstrated that liposuction combined with continuous compression therapy (CCT) is a safe and effective technique for treatment of primary and secondary lower extremity lymphedema (LEL), with a significant reduction of the original excess limb volume. Male patients with primary lymphoedema have the poorest outcomes. Limbs with secondary lymphoedema respond best to this treatment." Liposuction is commonly used to treat post-mastectomy arm lymphedema, and the medical literature indicates that liposuction is very effective for chronic lower extremity non-pitting chronic lymphedema. Liposuction is a standard of care for the treatment of minimally pitting lymphedema.