Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Lymphedema.
Treatment:  Vascularized lymph node (omentum) flap transfer with microanastomosis (CPT code 38999-2 units, 38792-2 units and 49906-1 unit) and 1 associated inpatient bed day.

The insurer denied coverage for vascularized lymph node (omentum) flap transfer with microanastomosis (CPT code 38999-2 units, 38792-2 units and 49906-1 unit) and 1 associated inpatient bed day.  The denial is overturned.

This is a female patient with a diagnosis of lymphedema of both extremities and pubic area.  The patient also had a diagnosis of cervical cancer and a past surgical history of laparoscopic hysterectomy and pelvic lymph node dissection and radiation therapy to the area.  The patient developed lymphoceles on both groins; right lymphocele drained on the right side after infection, and she was admitted to the hospital due to infection lymphedema.  The patient was treated with drainage and antibiotics.  The patient has developed Stage II lymphedema both lower extremities and pubic area.  The patient has exhausted conservative methods of treatment including daily lymphedema pumps, garments and lymphatic drainage, and is seeking a more permanent solution to her lymphedema.  The patient reports that she cannot perform well at her job due to her worsening lymphedema.  Her treating physician is recommending lymph node transfer with omentum and microanastomosis.

According to Forte et al., "Overall, patients experienced successful lymphedema treatment with vascularized omental lymph node transplant (VOLT) during the follow-up period (ranging from 0.5 to 48 months).  All [studies] present the results with the reduced circumferential size of the affected upper and lower limbs, as well as the reduction of infectious intercurrences, such as cellulitis, with a small incidence of associated complications." Kenworthy et al. also states that the "double VOLT is a safe and reliable technique for the treatment of lymphedema." As per Cornelissen et al., "Lymph node transfer has been performed to treat lymphedema for several years.  The goal of this procedure is to provide a bridge between the lymphatic system distal and proximal to the lymph node dissection." 

Based on literature review, there is medical evidence that demonstrates improvement in health in patients who have tried and exhausted conservative management, when they undergo the requested procedure, vascularized omental lymph node transplant (VOLT).  It is the recognized standard of care in patients with recalcitrant lymphedema, when other treatments and modalities treatment have failed.  The patient is a good candidate for this VOLT procedure.  The patient has exhausted other modalities of treatment, is young, and her lymphedema has been severe with complications including groin infections.

Thus, the requested procedure is likely to be more beneficial than any of the standard treatments/procedures for this patient.                        

The carrier's denial of vascularized lymph node (omentum) flap transfer with microanastomosis (CPT code 38999-2 units, 38792-2 units and 49906-1 unit) and 1 associated inpatient bed day should be overturned.