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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for free vascularized lymph node flap transfer (VLNT) and liposuction of bilateral upper extremities (including VLNT with microanastomosis; extensive scar release in axillary region; possible repair of native lymphatics; intraoperative lymphatic mapping of affected limbs; and liposuction of bilateral upper extremities. This patient presents with a history of breast cancer and stage II lymphedema, characterized by gross increase in size of the affected upper extremities due to edema and fibrofatty tissue deposits. The patients provider has recommended treatment with VLNT and liposuction. Lymphedema of the upper extremity as sequela of breast cancer treatment with mastectomy and radiation can have a severe impact on a patients quality of life, as it interferes with the ability to perform activities of daily living. VLNT involves removing normal lymph nodes with their blood supply and transplanting them into the lymphedematous extremity. Several studies have demonstrated that VLNT is beneficial in alleviating lymphedema, especially in the earlier stages. A variety of donor options for VLNT for the surgical treatment of lymphedema have been described. One study assessing vascularized omental lymph node transfer procedures tracked 42 patients who underwent a free omental lymphatic flap transfer with a mean follow-up of 14 months. The authors found that at eight-months follow-up, 83% of patients reported subjective improvements, and the arm circumference of these patients was reduced by 42.9% above the elbow, and 36.4% below the elbow. On review of the peer-reviewed medical literature, the requested free VLNT and liposuction of bilateral upper extremities is likely to provide this patient with an improved long-term health outcome as compared to compression or decongestive therapy. Based on the available evidence, the requested free VLNT and liposuction of bilateral upper extremities (including VLNT with microanastomosis; extensive scar release in axillary region; possible repair of native lymphatics; intraoperative lymphatic mapping of affected limbs; and liposuction of bilateral upper extremities are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested free VLNT and liposuction of bilateral upper extremities (including VLNT with microanastomosis; extensive scar release in axillary region; possible repair of native lymphatics; intraoperative lymphatic mapping of affected limbs; and liposuction of bilateral upper extremities are 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 services are 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 reviewer 1 is board certified in plastic surgery and is actively practicing. Physician reviewer 2 is board certified in plastic surgery and is actively practicing. Physician reviewer 3 is board certified in plastic surgery and is 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.