Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral lower extremity lymphedema
Treatment: Pneumatic Compression Device
The insurer denied coverage for the Pneumatic Compression Device. 
The denial is upheld.

This is a male patient with a past medical history of super morbid obesity, borderline diabetes mellitus and hypertension. The patient presented to an office visit for evaluation of lower extremity symptoms. The chief complaints were symptoms suggestive for venous disorder or thrombolytic event, and trouble fitting in shoes. The assessment revealed treatable superficial venous insufficiency of both legs. The plan was to continue conservative treatment with reassessment in 3 months, and the recommendation was for Flexitouch. An order was placed for the Flexitouch Pneumatic Compression Device (E0652) and Lower Garments (E0667 or E0669) for the treatment of the patient's bilateral lower extremity lymphedema.

While rare in men with super morbid obesity such as in this patient, this patient's leg swelling may actually be lipedema and not so much lymphedema, which could explain some failure of conservative therapy. This patient has a body mass index (BMI) of approximately 65, weighing 500 pounds. There are limitations in even applying and fitting compression stockings let alone trying to apply properly a Flexitouch system in such cases. According to Buso et al. (2019), "Lipedema is a chronic and progressive disease that can lead to considerable disability, daily functioning impairment, and psychosocial distress. It affects almost exclusively women, starting most often between puberty and the third decade of life. Lipedema involves abnormal deposition of subcutaneous adipose tissue, leading to a bilateral, disproportional volume increase of lower extremities and, in some cases, of arms. Fat deposition typically spares hands, feet, and trunk. Pathophysiological mechanisms of lipedema remain to be fully elucidated. Additionally, given the lack of consistent diagnostic criteria, its prevalence is difficult to establish, though it is thought to be common. Lipedema is in fact highly underdiagnosed by health care providers, being frequently misdiagnosed as obesity or lymphedema, diseases with which it shares several features."

As per Greene (2016), "Obesity-induced lymphedema of the lower extremities can occur once a patient's body mass index exceeds 50; individuals with a body mass index greater than 60 will likely have the condition. Upper extremity lymphedema may develop when the body mass index exceeds 80. Complications of obesity-induced lymphedema include infection, reduced ability to use the limb, and localized overgrowth. Diagnosis of obesity-induced lymphedema requires lymphoscintigraphy. Definitive management consists of weight loss and referral to a bariatric surgical center. Following weight loss, resection of excess skin and subcutaneous tissue may be necessary. Despite a significant body mass index reduction, lymphedema may not improve, resulting in chronic morbidity." 

Based on the review of the medical record and literature, the medical necessity of Pneumatic Compression Devices is based on failure of conservative therapy which includes treatment of any underlying conditions. This patient has theoretically treatable underlying venous reflux disease including at least bilateral great saphenous veins (GSV). Considering this patient's underlying cause of lymphedema is his super morbid obesity, this patient requires multidisciplinary and aggressive intervention for his obesity. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the Pneumatic Compression Device is not substantiated. The insurer's denial should be upheld.