Medical Policy: 07.01.76 

Original Effective Date: September 2017 

Reviewed: September 2018 

Revised: September 2018 

 

Notice:

This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.

 

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.

 

Management and Treatment

Early and ongoing treatment of lymphedema is necessary. Conservative therapy may consist of several features depending on the severity of the lymphedema. Patients are educated on the importance of self-care including hygiene practices to prevent infection, maintaining ideal body weight through diet and exercise, and limb elevation. Compression therapy consists of repeatedly applying padding and bandages or compression garments. Manual lymphatic drainage is a light pressure massage performed by trained physical therapists or by patients designed to move fluid from obstructed areas into functioning lymph vessels and lymph nodes. Complete decongestive therapy is a multiphase treatment program involving all of the previously mentioned conservative treatment components at different intensities. Pneumatic compression pumps may also be considered as an adjunct to conservative therapy or as an alternative to self-manual lymphatic drainage in patients who have difficulty performing self-manual lymphatic drainage. In patients with more advanced lymphedema after fat deposition and tissue fibrosis has occurred, palliative surgery using reductive techniques such as liposuction may be performed.

 

Surgery may be used as an adjunct to conservative therapy. Conservative therapy is multimodal. It involves meticulous skin hygiene and care, exercise, compression therapy, and physical therapy (manual lymphatic drainage). Complete decongestive therapy and pneumatic compression pumps are also used as adjuncts to conservative therapy. 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 (LVA)

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.

 

Lymphatic Microsurgical Preventing Healing Approach [LYMPHA]

The purpose of lymphatic physiologic microsurgery simultaneous to lymphadenectomy for breast cancer (ie, the Lymphatic Microsurgical Preventing Healing Approach [LYMPHA]) is to prevent lymphedema in individuals who are being treated for breast cancer. LYMPHA is a preventive LVA procedure performed during nodal dissection or reconstructive surgery that involves anastomosing arm lymphatics to a collateral branch of an axillary vein.

 

Guidelines and Position Statements

National Lymphedema Network

The National Lymphedema Network published a position paper on the diagnosis and treatment of lymphedema in 2011. The paper stated the following on microsurgical procedures:

“Microsurgical and supramicrosurgical (much smaller vessels) techniques have been developed to move lymph vessels to congested areas to try to improve lymphatic drainage. Surgeries involve connecting lymph vessels and veins, lymph nodes and veins, or lymph vessels to lymph vessels. Reductions in limb volume have been reported and a number of preliminary studies have been done, but there are no long-term studies of the effectiveness of these techniques.”

 

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 ]
  • 38531 Biopsy or excision of lymph node(s); open, inguinofemoral node(s)
  • 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
  • 15833 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.
  • International Society of Lymphology Executive Committee. The Diagnosis and Treatment of Peripheral Lymphedema: 2016 Consensus Document of the International Society of Lymphology. 2016;
  • 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.
  • Cornelissen AJM, Beugels J, Ewalds L, et al. The effect of lymphaticovenous anastomosis in breast cancer-related lymphedema: a review of the literature. Lymphat Res Biol. Jan 22 2018. PMID 29356596
  • Scaglioni MF, Fontein DBY, Arvanitakis M, et al. Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery. Nov 2017;37(8):947-953. PMID 28972280
  • Carl HM, Walia G, Bello R, et al. Systematic review of the surgical treatment of extremity lymphedema. J Reconstr Microsurg. Jul 2017;33(6):412-425. PMID 28235214
  • Jorgensen MG, Toyserkani NM, Sorensen JA. The effect of prophylactic lymphovenous anastomosis and shunts for preventing cancer-related lymphedema: a systematic review and meta-analysis. Microsurgery. Mar 28 2017. PMID 28370317
  • Scaglioni MF, Arvanitakis M, Chen YC, et al. Comprehensive review of vascularized lymph node transfers for lymphedema: Outcomes and complications. Microsurgery. Feb 2018;38(2):222-229. PMID 27270748

 

Policy History:

  • September 2018 - Annual Review, Policy Revised
  • 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.

 

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