Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Lower extremity lymphedema.
Treatment: Lymphatic venous bypass.
The insurer denied the lymphatic venous bypass. 
The health plan's determination is overturned. 

The patient is a male with left lower extremity lymphedema. He was diagnosed with angiomyolipomatous hamartoma. His lymphedema is thought to be secondary to lymphatic congestion in the groin from the angiomyomatous process. He has been compliant with compression and uses compression except when sleeping. Lymphatic venous anastomosis is planned.

At issue is the medical necessity of Lymphatic venous bypass (LVA).
I overturn the health plan's determination, in a whole.

Lymphaticovenous anastomosis (Lymphatic venous bypass) for this patient's leg edema is medically necessary, clinically appropriate, and generally accepted as a potentially curative treatment for lymphedema.

A 2020 Consensus Document of the International Society of Lymphology states:

"Lymphatic-venous (or lymphovenous) anastomoses (LVA) are currently in use at many centers around the world. These procedures have undergone confirmation of long-term patency (in some cases more than 25 years) and demonstration of improved lymphatic transport (by objective physiologic measurements of long-term efficacy)." [11]

In a study from MD Anderson Cancer Center, 95 percent (%) of patients had subjective improvement in symptoms and 65% had objective improvement in swelling. The procedure has a low morbidity with no complications recorded in the Chang series. A study by Demirtas et al concluded, " Supermicrosurgical lymphaticovenular anastomosis and/or lymphaticovenous implantation seems to be highly beneficial, especially in the early stages of peripheral lymphedema and may be offered as the treatment of choice in selected patients." Their study showed efficacy for both primary and secondary lymphedema. [3] A long-term follow-up (average 3.3 years) study by Koshirma et al concluded that "supermicrosurgical lymphaticovenular anastomosis has a valuable place in the treatment of lymphedema." [4] A study by Winters et al concluded, "Treatment with LVAs is effective in reducing arm volume difference in patients suffering from Breast cancer-related lymphedema (BCRL). Although no complete reduction of the edema was achieved at the 12-month follow-up, the procedure significantly increased the patients' quality of life (QoL)." [7] A study by Cornelissen et al concluded, "LVA for early-stage BCRL resulted in a significant improvement in quality of life and a high rate in stocking discontinuation." [8] A 2017 systematic literature review concluded, "Although the studies included in this review showed great heterogeneity, LVA surgery revealed both objective and subjective improvements in most patients." [9]

While prospective randomized studies have not been performed (and indeed would be exceedingly difficult to perform), these and other studies consistently show efficacy for LVA for breast cancer and lower extremity lymphedema such that the procedure should be considered a standard of care and not experimental. A 2020 systematic review of LVA for lower extremity lymphedema concluded, "LVA demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of LVA in LEL treatment." [10]

This patient has chronic lymphedema due to his angiomyomatous process. He will benefit from treatment now before he develops the progressive fibrosis that consistently occurs with untreated chronic lymphedema. LVA is a potentially curative treatment for this patient's condition and should be certified to prevent fibrosis and cellulitis. The requested LVA surgery is medically necessary and one of the few effective treatments for his condition.