Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic lymphedema.
Treatment: Vascularized lymph node transfer (VLNT) and lymphaticovenous anastomosis.

The insurer denied coverage for VLNT and lymphaticovenous anastomosis.  The denial is overturned. 

This is a female patient with a history of chronic lymphedema. She presented to the vascular surgeon's office for a 4-month follow up visit after having a suction assisted protein lipectomy (SAPL) of the left leg. Her left leg was visibly smaller than her right leg.  There was a positive Stemmer's sign at the toes. The patient had sufficient pitting edema. The physician noted that the patient would benefit from conservative therapy and a lymphatic drainage procedure. He recommended a vascularized lymph node transfer and lymphaticovenous anastomosis to treat the patient's lymphedema.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

Vascularized lymph node transfer and lymphaticovenous anastomosis to treat lymphedema (Codes: 38999 x3, 38900, 66990, 76499, 93971) has final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for vascularized lymph node transfer and lymphaticovenous anastomosis to treat lymphedema. Vascularized lymph node transfer and lymphaticovenous anastomosis to treat lymphedema is the best available treatment for this patient at this time.

The patient has exhausted all conservative methods of treatment for her lymphedema.  It is the reviewer's opinion that lympho-venous anastomosis or lymph node transfer is indicated and more beneficial.  The adverse risks are not increased over standard treatment/services.

This case involves a patient being evaluated for chronic lymphedema of her left lower extremity. The patient developed lymphedema after lymph node dissection and radiation after resection of a desmoid tumor. Lymphedema is a debilitating condition caused by failure of the lymphatic drainage system, and it is characterized by swelling and fibroadipose tissue deposition. Early lymphedema can be treated conservatively with compression, extremity elevation, and similar treatments to increase lymphatic flow.  Lympho-venous anastomoses is effective mainly in patients with early-stage lymphedema because of difficulty with finding functional lymphatics in patients with advanced stage lymphedema. However, functioning lymphatic vessels can be identified preoperatively using ultrasound and magnetic resonance lymphangiography; thus, lymphovenous anastomoses can effectively reduce the volume of the limb and improve subjective symptoms in patients with advanced stage lymphedema of the lower extremity.(1)  More commonly for later stages, vascularized lymph node transfer rather than lympho-venous anastomoses is used as a first treatment option.(2)  Although traditionally patients with later stage lymphedema were treated liposuction or other surgical debulking procedures, vascularized lymph node transfer has also been shown to be successful and provide improvement in these patients.(3)  The requested services are likely to be more beneficial than continued conservative management in this patient.

The carrier's denial of coverage for a vascularized lymph node transfer and lymphaticovenous anastomosis to treat lymphedema (Codes: 38999 x3, 38900, 66990, 76499, 93971) should be overturned.