Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with lipedema. The patient endorsed leg and hip pain for over 12 years. A computed tomography (CT) scan of the patients abdomen was unremarkable. A venous ultrasound of the patients legs was noted to be normal. The patient complained of fullness in the upper and lower extremities with bruising, swelling, and pain that was not responsive to diet and exercise. The patient reported that the pain affects her activities of daily living, and has been treated with gabapentin, Voltaren gel, compression stockings, and ice and heat. Later on, the patients body mass index (BMI) was 43. The patients photographs were reviewed. At issue in this case is whether lipedema lymph sparing liposuction surgeries to the calves, ankles, upper buttocks, hips, upper arms, to circumferential thighs, employing multiple modalities of Water Assisted Liposuction (WAL), VASER (ultrasonic), and Power Assisted Liposuction (PAL) using local anesthesia and manual lymphatic drainage therapy are medically necessary for the treatment of the patients medical condition. In addition, does the patients condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities; developmental abnormalities; trauma; infection; tumors or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient? As noted by researchers, lipedema is characterized most commonly by disproportionate adipocyte hypertrophy of the lower extremities, significant tenderness to palpation, and a failure to respond to extreme weight loss modalities. The authors found that due to lipedemas relatively unknown status in the medical community, there is a paucity of data regarding effective treatments of this disease. Relatively few studies have defined the precise pathogenesis, epidemiology, and management strategies for this disorder. Morbid obesity should be therapeutically addressed prior to liposuction. This patients records do not document failure of conservative management, including significant weight loss, as the patient reportedly has a BMI of 43. Therefore, lipedema lymph sparing liposuction surgeries to the calves, ankles, upper buttocks, hips, upper arms, to circumferential thighs, employing multiple modalities of WAL, VASER (ultrasonic), and PAL using local anesthesia and manual lymphatic drainage therapy are not medically necessary for the patient. In addition, the available medical literature does not provide quality studies on lipedema or well-designed studies regarding the effectiveness of treatment on a long-term basis. The patients condition does constitute an abnormal structure of the body. However, data has not established that the requested procedures would improve function or create a more than minimal improvement in the patients appearance. Overall, there is a lack of studies regarding the treatment of lipedema, particularly with the use of liposuction. Therefore, the requested lipedema lymph sparing liposuction surgeries to the calves, ankles, upper buttocks, hips, upper arms, to circumferential thighs, employing multiple modalities of WAL, VASER (ultrasonic), and PAL using local anesthesia and manual lymphatic drainage therapy are not reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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.