BlueCross and BlueShield of Montana Medical Policy/Codes
Surgery for Lymphedema
Chapter: Surgery: Procedures
Current Effective Date: September 24, 2013
Original Effective Date: September 24, 2013
Publish Date: June 24, 2013
Description

Lymphedema is an accumulation of lymphatic fluid in the interstitial tissue that causes swelling, most often in the arm and/or leg, and occasionally in other parts of the body.  Lymphedema can develop when lymphatic vessels are missing or impaired (primary), or when lymph vessels are damaged or lymph nodes removed (secondary).

When the impairment becomes so great that the lymphatic fluid exceeds the lymphatic transport capacity, an abnormal amount of protein-rich fluid collects in the tissues of the affected area.  Left untreated, this stagnant, protein-rich fluid not only causes tissue channels to increase in size and number, but also reduces oxygen availability in the transport system, interferes with wound healing, and provides a culture medium for bacteria that can result in lymphangitis.

Primary lymphedema, which can affect from one to as many as four limbs and/or other parts of the body, can be present at birth, develop at the onset of puberty or in adulthood, all from unknown causes, or associated with vascular anomalies such as hemangioma, lymphangioma, port wine stain or Klippel Trenaury.

Secondary lymphedema, or acquired lymphedema, can develop as a result of surgery, radiation, infection or trauma.  Specific surgeries, such as surgery for melanoma or breast, gynecological, head and neck, prostate or testicular, bladder or colon cancer, all of which currently require removal of lymph nodes, put patients at risk of developing secondary lymphedema.  If lymph nodes are removed, there is always a risk of developing lymphedema.

Secondary lymphedema can develop immediately post-operatively, or weeks, months, even years later.  It can also develop when chemotherapy is unwisely administered to the already affected area (the side on which the surgery was performed) or after repeated aspirations of a seroma (a pocket of fluid which occurs commonly post-operatively) in the axilla, around the breast incision, or groin area.  This often causes infection and, subsequently, lymphedema.

Lymphedema develops in stages, from mild to severe and is defined below:

Stage 1 (spontaneously reversible):

Tissue is still at the "pitting" stage, which means that when pressed by fingertips, the area indents and holds the indentation.  Usually, upon waking in the morning, the limb or affected area is normal or almost normal size.

Stage 2 (spontaneously irreversible):

The tissue now has a spongy consistency and is "non-pitting," meaning that when pressed by fingertips, the tissue bounces back without any indentation forming.  Fibrosis found in this stage of lymphedema marks the beginning of the hardening and increasing size of the limbs.

Stage 3 (lymphostatic elephantiasis):

At this stage the swelling is irreversible and usually the limbs are very large.  The tissue is hard (fibrotic) and unresponsive; some patients consider undergoing reconstructive surgery called "debulking" at this stage.

When lymphedema remains untreated, protein-rich fluid continues to accumulate, leading to an increase of swelling and a hardening or fibrosis of the tissue.  In this state, the swollen limb becomes a perfect culture medium for bacteria and subsequent recurrent lymphangitis.  Moreover, untreated lymphedema can lead into a decrease or loss of functioning of the limb, skin breakdown, chronic infections and, sometimes, irreversible complications.  In the most severe cases, untreated lymphedema can develop into a rare form of lymphatic cancer called lymphangiosarcoma (most often in secondary lymphedema).

Microsurgical techniques for the anastomosis of blood or lymphatic vessels have introduced a possible method for treating lymphedema in the extremities.  These techniques attempt to create a means for lymphatic fluid to by-pass the obstruction by being channeled through the venous system (lymphatic-venous anastomoses), or by using venous grafts between lymphatic collectors above and below the obstruction (lymphatic-venous-lymphatic plasty).

Policy

Investigational

Blue Cross and Blue Shield of Montana (BCBSMT) considers surgery for lymphedema (e.g., microsurgical lymphovenous anastomoses) experimental, investigational and unproven.

Federal Mandate

Federal mandate prohibits denial of any drug, device, or biological product fully approved by the FDA as investigational for the Federal Employee Program (FEP). In these instances coverage of these FDA-approved technologies are reviewed on the basis of medical necessity alone.

Rationale for Benefit Administration

This medical policy was developed through consideration of peer reviewed medical literature, FDA approval status, accepted standards of medical practice in Montana, Technology Evaluation Center evaluations, and the concept of medical necessity. BCBSMT reserves the right to make exceptions to policy that benefit the member when advances in technology or new medical information become available.

The purpose of medical policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment. Blue Cross and Blue Shield of Montana recognizes the rapidly changing nature of technological development and welcomes provider feedback on all medical policies.

When using this policy to determine whether a service, supply or device will be covered, please note that member contract language will take precedence over medical policy when there is a conflict.

Rationale

Harris and colleagues conducted a systematic review of literature retrieved from MEDLINE (1966-2000) and CANCERLIT (1985-2000) as well as a non-systematic review of breast cancer literature published to October 2000.  They concluded that surgery as a treatment option for lymphedema (e.g., microsurgical lymphovenous anastomoses) has produced disappointing, inconsistent results and should be avoided. 

The management of lymphedema in breast cancer patients is based primarily on results from case studies, clinical experience and anecdotal information.  The natural history and most effective therapies for lymphedema are poorly understood and need further study.  Accurate assessment requires agreement on a standardized and reliable system of measurement; randomized controlled trials to answer these questions should be encouraged. 

Gloviczki and colleagues from the Mayo Clinic followed their patients for an average of three years after microsurgical lymphovenous anastomosis for treatment of lymphedema.  All patients who underwent the operations had failed medical management that consisted of prolonged periods of intermittent compression with pneumatic pumps and elastic support.  Their trial was small, involving only 18 patients.  Fourteen patients were evaluated and of these, five had improvement, five were unchanged and four had progression of their lymphedema at the time of last follow up.  The authors concluded that there was no objective evidence supporting the value of microsurgical treatment for lymphedema.

Per the National Cancer Institute (NCI), lymphedema is treated by physical methods and drug therapy.  This includes compression garments, antibiotics, diuretics, anticoagulants and dietary management.  Surgery for treating lymphedema usually results in complications and is seldom recommended for cancer patients.

The trials that report on surgical techniques to treat lymphedema are very small with little follow up and inadequate information regarding the outcome of those patients where the surgery was ineffective.  

Surgery for lymphedema is considered experimental, investigational and unproven due to lack of adequate evidence of safety and effectiveness documented in published, peer-reviewed medical literature.

2011 Update

A search of peer reviewed literature through November 2011 was performed.  The following is a summary of the key literature to date.

Mukenge S.M., et al. reported on a study that included patients with external male genital organ lymphedema.  In this study a novel surgical technique was used, this surgical technique was a microsurgical lymphovenous derivation.  The patency of lymphovenous anastomoses was assessed by noninvasive lymphography at 3, 6, and 12 months after surgery.  Five of the 11 patients underwent the microsurgical lymphovenous derivation.  The authors noted

“The present study shows that lymphovenous anastomosis is a valuable method of resolving the edematous condition.”  The authors also noted the low number of patients enrolled in the study as a possible limitation of the study.  This update failed to identify any additional information that would change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies           

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

Experimental, investigational and unproven for all diagnoses.

ICD-10 Codes

Experimental, investigational and unproven for all diagnoses.

Procedural Codes: 15758, 38999
References
  1. Gloviczki, P., Fisher, J., et al.  Microsurgical lymphovenous anastomosis for treatment of lymphedema: A critical review.  Journal of Vascular Surgery (1988) 7:647-52.
  2. Harris, S., Hugi, M., et al.  Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema.  Canadian Medical Association Journal (2001) 164 (2): 191-199.
  3. National Lymphedema Network.  Lymphedema FAQ.  Available at www.lymphnet.org (accessed – 2009 February 17).
  4. National Cancer Institute.  Lymphedema.  Available at www.cancer.gov (accessed – 2009 February 17).
  5. Mukenge S.M., Catena M. et al.  Assessment and follow-up of patency after lymphovenous microsurgery for treatment of secondary lymphedema in external male genital organs.  European Urology 2011 November: 60(5):1114-9.  [Epub 2010 November 24]
History
June 2013  New 2013 BCBSMT medical policy.  Surgery for lymphedema (e.g., microsurgical lymphovenous anastomoses) is considered experimental, investigational and unproven.
BCBSMT Home
®Registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. ®LIVE SMART. LIVE HEALTHY. is a registered mark of BCBSMT, an independent licensee of the Blue Cross and Blue Shield Association, serving the residents and businesses of Montana.
CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Surgery for Lymphedema