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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lymphatic massage following a VASER liposuction procedure. This patient has excess fatty tissue throughout her body, with a diagnosis of lipedema versus exogenous obesity with a BMI of 39.0 kg/m2. The patient reports that she was diagnosed with lipedema in June 2019. Physical examination reported adiposity along bilateral buttocks, thighs, and the knees, with some adiposity around the lower legs. She has adiposity around her upper posterior arms as well as rounded truncal adiposity. She has undergone two stages of liposuction for reduction of the fatty tissue in her lower extremities. She planned for a third procedure. Additional treatments have included Lasix for over 10 years and manual lymphatic drainage. Lymphatic massage is supported for the treatment of lymphedema, not lipedema. Lymphedema is a collection of fluid, while lipedema is a collection of fat. While the two conditions can co-exist, they are separate entities. Physical examination reported bilateral legs without edema but with adiposity. Stemmers sign, which is positive with lymphedema, was negative bilaterally. There is no history of treatment for lymphedema except for use of compression garments. In addition, the patient challenged the diagnosis of lymphedema, and her providers, including vascular surgery and plastic surgery, concur with the diagnosis of lipedema. Peled and Kappos noted that lipedema is characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The authors found that, One of the major distinguishing features of lipedema is the sparing of the feet, which can create a distinct step-off at the ankle. Kayiran and colleagues reported that, primary lymphedema is related to developmental abnormalities of the lymphatic system whereas secondary lymphedema is attributed to the impairment of lymphatic vessels due to an acquired condition such as trauma, tumor, surgery or infection. Liposuction has been shown to improve lymphedema and attendant lymph flow. In addition, manual lymphatic drainage techniques have been demonstrated to improve some symptoms of lipedema. However, post liposuction edema is managed with compression alone in large volume suction cases. Overall, there is a paucity of controlled clinical studies demonstrating improved patient health outcomes with use of lymphatic massage as treatment for lipedema in the postoperative patient. All told, the requested lymphatic massage following a VASER liposuction procedure is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. 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.