Blue Cross Blue Shield of Minnesota Medical Policy

 
 
Medical Policy:
IV-158-004
Topic:
Surgical Treatments of Lymphedema
Section:
Surgery
Effective Date:
November 1, 2020
Issued Date:
May 31, 2021
Last Revision Date:
August 2020
Annual Review:
May 2021
 
 

This policy version was replaced May 30, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Lymphedema is the swelling of subcutaneous tissues due to the accumulation of excessive lymph fluid. The accumulation of lymph fluid results from impairment to the normal clearing function of the lymphatic system and/or from an excessive production of lymph. Lymphedema is divided into two broad classes according to etiology. Primary lymphedema is a relatively uncommon, chronic condition which may be due to such causes as Milroy's Disease or congenital anomalies. Secondary lymphedema, which is much more common, results from the destruction of or damage to formerly functioning lymphatic channels, such as surgical removal of lymph nodes or post radiation fibrosis, among other causes.

Surgery has been suggested for those with refractory lymphedema which has not improved with conservative treatment. These procedures include:

  • lymph node transfer, also known as vascularized lymph node transfer (VLNT), which transfers healthy lymph nodes from an unaffected site to the site of obstruction, with the intent of restoring lymphatic function;
  • lymphaticovenous (lymphaticovenular) anastomosis, which reconstructs lymph vessels to redirect the excess lymph fluid into the venous circulation;
  • lymphovenous bypass, in which a vein graft is used to connect the distal lymphatic vessels with vessels proximal to the obstruction,
  • lymphatic-lymphatic bypass, which connects functioning lymphatic vessels directly to the affected lymphatic vessels.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Note: Suction assisted lipectomy/suction assisted protein lipectomy is addressed in medical policy IV-82, Liposuction.

I.    Surgical treatment of lymphedema, including but not limited to the following procedures, is considered EXPERIMENTAL/INVESTIGATIVE due to the lack of clinical evidence demonstrating an impact on improved health outcomes:

  • Vascularized lymph node transfer (VLNT);
  • Lymphaticovenous (lymphaticovenular) anastomosis (LVA);
  • Lymphovenous bypass;
  • Lymphatic-lymphatic bypass.

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Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.

Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.

Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites. 

Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. 

These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Acknowledgements:

CPT® codes copyright American Medical Association® 2022. All rights reserved.

CDT codes copyright American Dental Association® 2022. All rights reserved.