Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lymphedema
Treatment: Hemic or Lymphatic System (Code: 38999x12); Intraoperative Identification of Sentinel Lymph Node(s) includes Injection of Non-Radioactive Dye when Performed (Code: 38900); Duplex Scan of Extremity Veins including Responses to 
Compression and other Maneuvers Unilateral or Limited Study (Code: 93971); Microsurgical Techniques, Requiring Use of Operating Microscope; Two Inpatient Days (Code: 69990)
The insurer denied: Hemic or Lymphatic System (Code: 38999x12); Intraoperative Identification of Sentinel Lymph Node(s) includes Injection of Non-Radioactive Dye when Performed (Code: 38900); Duplex Scan of Extremity Veins including Responses to Compression and other Maneuvers Unilateral or Limited Study (Code: 93971); Microsurgical Techniques, Requiring Use of Operating Microscope; Two Inpatient Days (Code: 69990)
The denial is overturned.

This adult female presented with severe lymphedema of the right leg, extending from ankle to thigh. The condition began when she was in her 20s. Her condition was severe enough to substantially affect her function. She was unable to carry out many normal activities. She spent a great deal of time with conservative management of the condition, including compression garments, manual lymphatic drainage, exercise, and leg elevation. She also used a Flexitouch compression pump regularly. The patient underwent suction-assisted protein lipectomy (SAPL), which was effective in reducing some of her symptoms. However, she has persistent swelling that remains difficult to manage. The provider has now recommended additional surgery, namely vascularized lymph node transfer (VLNT) and/or lymphovenous anastomosis (LVA), along with sentinel node biopsy and lymphatic mapping. These procedures have been denied as being experimental/investigational.

The health plan should cover the proposed treatment.

Initial management of lymphedema is conservative and includes complete decongestive physiotherapy (multilayer low-stretch bandage, manual lymph drainage, skin care, exercises). Patients who fail conservative therapy can be considered for surgery. A recent systematic review concluded that "Intra-abdominal VLNT is an effective technique for patients with lymphedema with no obvious impairment to donor-site lymph function, as long as the operation is properly performed." (1) Another similar review found that the "current evidence indicates that VLNT can improve the volume differences between the arms in patients with unilateral lymphedema by approximately 40%. In addition, although determined from a few studies, it is likely that VLNT has a positive effect on patients' QoL, the number of skin infections, and compression garment usage and coincided with a low complication rate." (2) Lymphaticovenous anastomosis (LVA) is another surgical procedure that can treat lymphedema. During lymphaticovenous anastomosis, lymphatic vessels in the affected limb are connected to nearby veins. This allows lymph to drain into the veins and circulate back into the rest of the body. The goal of lymphaticovenous anastomosis is to decrease swelling, increase comfort, and decrease the need for compression garments. In a recent systematic review, authors found that "LVA demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of LVA in LEL treatment." (3)
Vascularized lymph node transfer (VLNT) and lymphaticovenous anastomosis (LVA) are medically indicated in patients who: 
1. Have lymphedema severe enough to adversely affect normal function; 
2. Have failed a trial of conservative therapy; and 
3. Are evaluated and treated in a specialized treatment center. This last requirement is important because surgical treatment of lymphedema is uncommon and is associated with high rates of failure when undertaken by inexperienced surgeons.
In the case under review, criterion 1 has been met. The patient has well documented severe symptoms leading to significant adverse effect on her function. The suction-assisted protein lipectomy surgery has helped to some extent, but she has persistent, severe swelling of the leg. 
Criterion 2 has been met. The patient has failed an exhaustive program of conservative therapy that included complete decongestive therapy and a home pump. Even after suction-assisted protein lipectomy, she continues to use heavy compression bandages for most of each day. 
Criterion 3 has been satisfied. The Provider is a well-published plastic surgeon with extensive experience in the area of lymphedema surgery. Many of his articles are in the field of 
lymphedema surgery.