Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lipedema
Treatment: 15879 - Suction assisted lipectomy, lower extremity, bilateral x 2; 27337 - Excision, tumor, soft tissue of thigh or knee area, subcutaneous, 3cm or greater, bilateral; 01520 -  Anesthesia for procedures on veins of lower leg, not otherwise specified
The health plan denied 15879 - Suction assisted lipectomy, lower extremity, bilateral x 2; 27337 - Excision, tumor, soft tissue of thigh or knee area, subcutaneous, 3cm or greater, bilateral; 01520 -  Anesthesia for procedures on veins of lower leg, not otherwise specified. 

The denial is partially overturned. 

The patient is an adult female. She complains of painful nodular fat accumulation in the limbs and lower abdomen with easy bruising, problems with balance and stair climbing, heavy legs, knee pain and stiffness aggravated by bending or prolonged sitting, standing or walking and parasthesias of the hands and feet. Pneumatic compression, compression garments,massage, knee braces, exercise and diet did not provide relief. Relief is only provided by lying down with legs elevated. Her medical history is notable for fibromyalgia, ehlers danlos and a torn meniscus. At examination there was nodular fat accumulation in the arms, infraumbilical abdomen and thighs with sparing of the hands and feet and wrist cuffing.

Functional capacity evaluation showed normal range of motion in the arms and legs and normal muscle strength in the shoulders, arms and legs but some weakening of the hip muscles and trunk extension/flexion, decreased standing tolerance, lower extremity functional scale score 27/80 and disabilities of arm shoulder and hand score of 42.5% (percent). The worst scale scores are 0/80 and 100%. The patient was able to lift up to 11 pounds from a 17 inch surface and 5 pounds from waist to crown but is unable to lift from the floor or fully squat or run.

The patient underwent covered lipoadominoplasty with umbilical hernia repair apparently with some liposuction (records are not included), and coverage-contested circumferential thigh liposuction with total aspirate 3700cc (cubic centimeters). The operative report only describes liposuction. It does not describe separate excision of any tissue.

Undated photos show normal arm to torso angle with arms abducted 90 degrees and are too poor quality for further assessment.

15879 - Suction assisted lipectomy, lower extremity, bilateral x 2 is medically necessary. 27337 - Excision, tumor, soft tissue of thigh or knee area, subcutaneous, 3cm or greater, bilateral and 01520 -  Anesthesia for procedures on veins of lower leg, not otherwise specified are not medically necessary.

Lipedema reduction surgery/liposuction of the legs significantly improves symptoms, mobility, stance, gait, valgus rotation/deformity of the knee and ankle, quality of life, and redistributes and restores the plantar arch. It also improves lymphatic symptoms, reducing the need for compression and manual therapy and improves lymphatic function as shown by radionucleotide lymphangioscintigraphy. The Herbst et al published report of national expert opinion does not clearly state benefits of liposuction for lipedema beyond the legs where joint damage can be prevented or reversed. Therefore, 15879 x2 was medically necessary.

27337 was not medically necessary because the operative report does not describe it as having been performed. It only describes liposuction.

01520 was not medically necessary because Per National Correct Coding Initiatives surgeons cannot bill for local anesthesia injected at the time of surgery as this is considered bundled into the CPT (Current Procedural Terminology) code of the surgery. Therefore 01520 is not billable, and doing so is unbundling.