Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 54-year-old female who has been diagnosed with lipedema. The patient has requested reimbursement for suction assisted lipectomy, trunk, suction assisted lipectomy, upper extremity and suction assisted lipectomy, lower extremity performed on 6/11/20, 8/13/20, 10/01/20 and 11/18/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient and were not reconstructive in nature. The physician reviewer found that Peled and Kappos note, aLipedema 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.a The authors noted, aOne of the major distinguishing features of lipedema is the sparing of the feet, which can create a distinct step-off at the ankleaDistinguishing 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.a Reich-Schupke and colleagues stated, aThe 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.a The authors noted, aTreatment 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.a Herbst and colleagues stated, aRemoval 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.a This patient has morbid obesity. Photographs show generalized weight deposition with significant truncal fat and omental fat. The weight in the limbs is not disproportionate to the weight in the trunk. Discrete ankle cuffing or bracelet effect is not visible in the photographs received for review. Wrist cuffing is not visible on the photographs received for review. There is no history of pain and hypersensitivity to touch, and there is no documentation of easy bruising. She complains of severe difficulty ambulating, but she has symptomatic osteoarthritis of her knees and hips with limitation of range of motion due to joint pain. Based on the medical history and the photographs received for review, the patient does not have documented lipedema. 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 or (2) to create a normal appearance, to the extent possible. The patient has morbid obesity without documentation of lipedema. Obesity is an abnormal structure of the body. Obesity is considered an endocrine disorder. It is a structural change that is an accommodative response to fat cell response to endocrine inputs. The appearance of the patient is consistent with the gain of weight. The services at issue are likely to both improve function and create a normal appearance, to the extent possible. The California Reconstructive Surgery Act is applicable to this patient. Therefore, lipectomy, trunk, suction assisted lipectomy, upper extremity and suction assisted lipectomy, lower extremity performed on 6/11/20, 8/13/20, 10/01/20 and 11/18/20 were reconstructive in nature.