Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) bilateral lymph sparing liposuction to upper and lower extremities and trunk and (2) excision of excessive skin/subcutaneous tissue to bilateral thigh, legs, arms and trunk. Warren Peled and Kappos state, Lipedema is an uncommon disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The adiposity extends from hips to ankles and is typically unresponsive to weight loss. In addition to the aesthetic deformity, women also describe pain in the lower extremities, particularly with pressure, as well as easy bruising. Although the condition is well described, it is relatively rare and often misdiagnosed. The authors further note, Distinguishing lipedema from other conditions causing fatty excess in the lower extremities can be difficult. Making the diagnosis relies on some of the hallmark characteristics of lipedema, such as the easy bruising and pain with soft tissue pressure, as well as the step-off at the ankles. Women with generalized obesity typically do not have these history and physical exam characteristics. Additionally, although many patients with lipedema may also be overweight, those who have tried to lose weight through diet and exercise typically find that reducing the size of their legs is very challenging, which is often not the case in women with standard obesity. This distinction is less clear, however, in women who have localized adiposity in the lower extremities that is not due to lipedema. Similar to lipedema, localized adiposity in some areas of the legs, particularly the outer thighs, around the knees, and the lower calves, can be very resistant to diet and exercise in some women. Further, some women with lipedema may also have additional areas of localized adiposity, making the diagnosis even more challenging.Reich-Schupke and colleagues state, The diagnosis [of lipedema] is established on the basis of medical history and clinical findings. Characteristically, there is a localized, symmetrical increase in subcutaneous adipose tissue in arms and legs that is in marked disproportion to the trunk. Other findings include edema, easy bruising, and increased tenderness. Further diagnostic tests are usually reserved for special cases that require additional workup. Lipedema is a chronic, progressive disorder marked by the individual variability and unpredictability of its clinical course. The authors further note, Treatment consists of four therapeutic mainstays that should be combined as necessary and address current clinical symptoms: complex physical therapy (manual lymphatic drainage, compression therapy, exercise therapy, and skin care), liposuction and plastic surgery, diet, and physical activity, as well as psychotherapy if necessary. Surgical procedures are indicated if  despite thorough conservative treatment  symptoms persist, or if there is progression of clinical findings and/or symptoms. If present, morbid obesity should be therapeutically addressed prior to liposuction.Herbst states, Removal of lipedema fat by liposuction that spares lymphatic vessels (wet, not dry, technique) has been performed primarily in Europe, especially in Germany, since the 1990s. The fat is saturated with Klein solution, which includes saline or lactated Ringers solution, an anesthetic such as lidocaine or prilocaine, epinephrine, sodium bicarbonate buffer, usually without steroid. This tumescent technique provides turgor to the tissue allowing blunt microcannula to slide through the fat tissue avoiding creation of shearing forces and tissue damage. When power assisted, tiny, rapid vibrations of the microcannula break up fat which is then suctioned out of the tissue. Water jet assisted liposuction (WAL) uses jets of saline and Klein solution to release fat for suction with minimal damage to cells and vessels without the waiting period required to tumesce the tissue. Laser assisted tumescent liposuction is another technique which some reserve for fibrotic areas such as the posterior thighs.In this case, the records do not reflect a diagnosis of symptomatic lipedema. Rather, the patient appears to have residual obesity. The patient is status post gastric bypass in 2011 and has since lost 135 pounds. While the patient reports pain in her arms and legs, the submitted documentation does not show painful nodules, pain with soft tissue pressure, or easy bruising. Photographs of the patient show significant residual adiposity in the buttocks and lower extremities from prior morbid obesity, without ankle cuffing with a step-off at the ankles. Given that current medical literature does not support a diagnosis of symptomatic lipedema in this clinical setting, the requested services are not medically indicated. Therefore, (1) bilateral lymph sparing liposuction to upper and lower extremities and trunk and (2) excision of excessive skin/subcutaneous tissue to bilateral thigh, legs, arms and trunk are not medically necessary for the treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, residual adiposity after gastric bypass is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease, and is not an abnormal structure of the body. Given that residual adiposity after gastric bypass is a normal accommodative response to the gain or loss of body mass, the requested (1) bilateral lymph sparing liposuction to upper and lower extremities and trunk and (2) excision of excessive skin/subcutaneous tissue to bilateral thigh, legs, arms and trunk are not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert 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.