Medical Policy: 07.01.76 

Original Effective Date: September 2017 

Reviewed: September 2017 

Revised:  

 

Benefit Application:

Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

 

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

 

Description:

Lymphedema 

Lymphedema, a less common form of edema, is a result of an abnormality of the lymphatic system. It is divided into two broad classes according to etiology, primary and secondary. Primary lymphedema is further divided into three categories of primary causes for lymphedema, which vary by their age at onset. Secondary lymphedema, which is much more common, results from the destruction of or damage to formerly functioning lymphatic channels, such as lymph node dissection or radiation, malignant obstruction, and infection. The goal of treatment is to control limb swelling, since the underlying disease cannot usually be corrected.

 

Lymphedema is usually staged by observing a patient’s physical condition.  The International Society of Lymphology uses the following 3-stage scale for classification of a lymphedematous limb:

  • Stage 1: Early accumulation of fluid relatively high in protein content (e.g., in comparison with "venous" edema) that subsides with limb elevation.  Pitting may occur.
  • Stage II: Limb elevation alone rarely reduces tissue swelling and pitting may or may not occur as tissue fibrosis develops.
  • Stage III: Lymphostatic elephantiasis.  Pitting is absent and trophic skin changes such as acanthosis, fat deposits, and warty overgrowths develop.

An increasing number of lymphologists recognize an earlier stage of lymphedema, termed Stage 0, which refers to a latent or subclinical condition where swelling is not evident despite impaired lymphatic transport.  Stage 0 may exist for months or years before the onset of overt lymphedema.

 

There is no consensus regarding the role of surgery, the optimal surgical approach, or the timing of an operative procedure for extremity lymphedema.

 

Suction Assisted Liposuction/Suction Assisted Lipectomy/ SALCESE 

Suction-assisted lipectomy in combination with excision of skin excess (SALCESE) is a procedure that combines the benefits of bulk reduction from lipectomy with the benefits of facilitated wound healing from the skin excision.

 

Microsurgical Lymphatico-Venous Anastomosis 

This procedure uses microsurgery to build tiny bridges between the lymphatic vessels and the veins, so that the lymph fluid has a new pathway out of the arm. However, it hasn’t been proven effective in the small research studies available.

 

Lymph Node Transfer 

In this approach, the surgeon "harvests" lymph nodes and their attached blood vessels from another area of the body — such as the abdomen or groin — and then connects them to the lymph vessels and blood vessels under the arm. Another technique involves implanting the nodes into the wrist of the arm affected by lymphedema. Some small, early studies have found that the procedure can offer relief from severe swelling, heaviness in the limb, and infections, although it doesn’t cure the lymphedema. There is some concern that the procedure actually could cause lymphedema in the other area of the body from which the lymph nodes were taken.

 

Prior Approval:

 

Not applicable

 

Policy:

The surgical treatment of lymphedema, including but not limited to, microsurgical lymphatico-venous anastomosis, suction assisted lipectomy or liposuction and vascularized lymph node transfer techniques is considered investigational.

 

Only small studies have looked at whether surgery may be helpful in cases where particularly aggressive or advanced lymphedema doesn’t respond to other treatments. Although some early results are promising, surgery is considered investigational and isn’t widely available or considered standard of care. Surgery is not curative and the long term efficacy cannot be proven with the available literature at this time.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.

  • 38308 Lymphangiotomy or other operations on lymphatic channels [lymphatic-capsular-venous anastomosis, lymphovenous bypass, or lymph node transfer- Medical Review ]
  • 38999 Unlisted procedure, hemic or lymphatic system
  • 15877 Suction assisted lipectomy; trunk
  • 15878 Suction assisted lipectomy; upper extremity
  • 15879 Suction assisted lipectomy; lower extremity
  • 15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
  • 18533 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
  • 15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm

 

Selected References:

  • Cormier JN, Rourke L, Crosby M, Chang D, Armer J. The Surgical Treatment of Lymphedema: A Systematic Review of the Contemporary Literature (2004- 2010). Ann Surg Oncol. Aug 24 2011.

  • Mehrara BJ, Zampell JC, Suami H, Chang DW. Surgical management of lymphedema: past, present, and future. Lymphat Res Biol. 2011;9(3):159-167.

  • Garza, R., Skoracki, R., Hock, K., & Povoski, S. P. (2017). A comprehensive overview on the surgical management of secondary lymphedema of the upper and lower extremities related to prior oncologic therapies. BMC Cancer, 17, 468.

  • Carl HM, Walia G, Bello R, et al. Systematic review of the surgical treatment of extremity lymphedema. J Reconstr Microsurg. 2017 Feb 24 [Epub ahead of print].

  • Cornelissen AJ, Qiu SS, Lopez Penha T, et al. Outcomes of vascularized versus non-vascularized lymph node transplant in animal models for lymphedema. Review of the literature. J Surg Oncol. 2017;115(1):32-36.

  • Ozturk CN, Ozturk C, Glasgow M, et al. Free vascularized lymph node transfer for treatment of lymphedema: A systematic evidence based review. J Plast Reconstr Aesthet Surg. 2016;69(9):1234-1247.

  • Granzow JW, Soderberg JM, Dauphine C. A novel two-stage surgical approach to treat chronic lymphedema. Breast J. 2014;20(4):420-422.

  • Granzow JW, Soderberg JM, Kaji AH, Dauphine C. An effective system of surgical treatment of lymphedema. Ann Surg Oncol. 2014b;21(4):1189-1194.

  • Mehrara B. Operative management of primary and secondary lymphedema. UpToDate]. Waltham, MA

  • Clinical Resource Efficiency Support Team (CREST). Guidelines for the diagnosis, assessment and management of lymphoedema. Belfast, Northern Ireland; CREST; February 2008.

  • International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema. 2009 Concensus Document of the International Society of Lymphology. Lymphology. 2009;42(2):51-60.

  • Campisi, Corrado Cesare, et al. "Fibro-Lipo-Lymph-Aspiration With a Lymph Vessel Sparing Procedure to Treat Advanced Lymphedema After Multiple Lymphatic-Venous Anastomoses: The Complete Treatment Protocol." Annals of Plastic Surgery (2016).

  • National Institute of Clinical Excellence. NICE interventional procedure guidance [IPG251], Liposuction for chronic lymphoedema. February 2008.

 

Policy History:

  • September 2017 - New Policy

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

 

*CPT® is a registered trademark of the American Medical Association.