Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 19-year-old female enrollee has requested authorization and coverage for liposuction, CPT code 15879 (suction assisted lipectomy of the lower extremity) and 38999 (unlisted procedure hemic or lymphatic system).  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees lipedema. The physician reviewer found that the patient has well documented evidence of chronic, painful lipedema of the lower extremities that is affecting her ability to ambulate. Conservative therapy has included medical management, compression garments, physical therapy and attempted weight loss without an improvement in her function. Photographs show a condition of the lower extremities consistent with lipedema, with a predictable pattern of enlarged lower extremities with sparing of the feet and distal portion of the legs.  Liposuction is a well-known therapy for lipodystrophy and has been shown to provide possible functional improvement in lipedema. Warren and colleagues noted, Lymphedema and lipedema, two related but distinct disorders leading to lower extremity swelling, have unique clinical features and findings on diagnostic testing and should be excluded as possible causes. Surgical therapy has traditionally involved surgical debulking procedures, which have shown varied postoperative outcomes, although reports using suction lipectomy have been more promising. From Schmeller and colleagues, they note Tumescent liposuction is a highly effective treatment for lipedema with good morphological and functional long-term results. Overall, from review of the medical documentation and relevant medical literature, the patient has a well-recognized condition of lipedema significantly affecting her function that has failed treatment with reasonable conservative measures. Additionally, her photographs are consistent with the overall clinical scenario. Multiple providers, other than the requesting surgeon, have provided supporting documentation for her surgical treatment.  Liposuction is well known to be very effective in removing fatty tissue and can be safe and effective. In this case, the patients diagnosis confirms the presence of diseased fatty accumulation which is well documented to be adversely affecting her function. Although liposuction is generally considered a cosmetic intervention, in this case, there is functional impairment that is being addressed. She has failed conservative management and there is no other service available that would likely have a beneficial effect. Thus, as no other treatment appears reasonable to provide possible functional improvement, liposuction of the lower extremities is medically indicated. This is consistent with peer reviewed literature as documented above. Based on the overall clinical documentation for this patient, CPT code 15879 (suction assisted lipectomy of the lower extremity) is medically necessary for treatment of this patients medical condition.  However, CPT code 38999, (an unlisted hemic or lymphatic system procedure) is not medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, a portion of the requested services is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.