Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a vascularized lymph node transfer VLNT microsurgical procedure. Lymphedema of the upper extremity is mostly a sequela of breast cancer treatment with mastectomy and radiation, often referred to as breast cancerrelated lymphedema, that has a severe impact on quality-of-life, as it interferes with most activities of daily living. Risk factors include a large number of lymph nodes removed, a larger size of primary tumor, exposure to multifield radiation, higher BMI, and upper outer quadrant tumor site. VLNT involves removing normal lymph nodes with their blood supply from a normal place and transplanting them into the lymphedematous extremity. Current medical literature supports the efficacy of VLNT in alleviating lymphedema, especially at earlier stages. Medical literature shows, A variety of donor options for vascularized lymph node transfer for the surgical treatment of lymphedema have been described. Intra-abdominal harvest sites including the gastroepiploic nodes within the omental flap and the mesenteric node flap are distinguished from their extra-abdominal counterparts by the absent risk of iatrogenic donor site lymphedema and discrete scar location, as well as the ability to harvest up to three vascularized nodal packets from one donor site. In a meta-analysis of intra-abdominal VLNT procedures including 21 studies with 594 patients, researchers found, Donor-sites of flaps were omental/gastroepiploic, jejunal, ileocecal, and appendicular. The mean reduction rate swelling ranged from 0.38% to 70.8%. Significant reduction in infectious episodes was reported in ten studies. The pooled donor-site complication rate was 1.4%  The pooled recipient-site complication rate was 3.2%. Researchers tracked 42 patients who underwent a free omental lymphatic flap transfer with a mean follow-up of 14 months. The authors report that subjective improvements were noted in 83% of patients and mean volumetric improvement was 22%. In a systematic review of omental lymph node transfer for lymphedema patients, researchers report that overall, patients experienced successful lymphedema treatment with vascularized omentum lymph node transfer, with reduced circumferential size of the affected upper and lower limbs, as well as reduction of the infectious intercurrences, such as cellulitis, with a small incidence of associated complications. Given that static management of lymphedema does not create longterm improvement and at best slows the progression of this permanent disease, VLNT is likely to be more beneficial than standard treatment for promoting long-term improvement in lymphedema. Therefore, a VLNT microsurgical procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested vascularized lymph node transfer microsurgical procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in plastic surgery and are actively practicing. The reviewers are experts 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.