Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lymphedema.
Treatment: Continued Physical Therapy.

The insurer denied the Continued Physical Therapy.  The denial is upheld. 

The records report that the patient is a female with a history of left breast surgery with subsequent swelling in the left arm for which she received lymphedema decongestive therapy.

Two years prior, the patient underwent two right lung surgeries, including an upper lobe lobectomy and partial middle lobe resection for removal of a lung lesion.  These surgeries were complicated by pain attributed to intercostal nerve pathology and right trunk lymphedema.  She saw a pain management physician who prescribed gabapentin and also referred her to occupational therapy for lymphedema management.  She underwent therapy at a facility for approximately five months, under the same therapist who treated her following the left breast surgery.  The therapy ceased due to the COVID-19 pandemic, in light of her compromised immune status.

Approximately eight months later, the patient returned to therapy with persistent fluctuating swelling in the right upper quadrant of the trunk and in the abdomen.  Therapy resumed. Approximately three months after returning to therapy, the patient was noted to have decreasing abdominal swelling.  She was noted to be benefitting from Kinesiotape to the abdomen.  Approximately one month later, the patient was noted to be improving.  There was decreased pain.  She was wearing a compression garment that had to be removed for food consumption due to increased reflux symptoms.  There was increased swelling by each evening.  Continued complex lymphatic drainage was recommended.

No, the proposed continued physical therapy was not medically necessary.

In general, there is a dearth of high-grade medical literature related to lymphedema management.  This is due to various challenges, including the lack of consistent criteria for diagnosing lymphedema and the highly variable presentations seen in patients.  In particular, there is a dearth of high-grade literature related to the management of lymphedema affecting the trunk/abdomen.  The mainstay of treatment is conservative management that generally follows the principles of complete decongestive therapy for the limbs.  This treatment includes: good skin care; specialized massage to redirect lymph flow, followed by compressive bandaging; exercise; and ultimately patient self-care for continued improvement and maintenance.

In the present case, the patient had undergone extensive formal lymphedema management for her condition, to include complete decongestive therapy.  She had a compression garment that was being worn at home, which was not tolerated during eating due to reflux symptoms.  Given that she had completed a complete decongestive therapy program and was using compression garment(s) for the home, she was therefore at a maintenance phase in her management and there was no indication for further formal lymphedema therapy during the time period under review.  Her physician's examinations during the course of her treatment, notably, did not document the presence of any lymphedema at the trunk or in any other location.

The records do not indicate that the service in question was medically necessary for the patient.  She had already undergone extensive formal lymphedema therapy and had maximized the benefits she was going to derive from formal lymphedema therapy for the time being, i.e., until there is a substantial change in her condition.  While the patient continued to have some swelling and persistent symptomatology, she was at a maintenance phase in her management and no longer required the services in question.