Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut SURG.00154 Microsurgical Procedures for the Prevention or Treatment of Lymphedema Form

Effective Date

04/12/2023

Last Reviewed

02/16/2023

Original Document

  Reference



This document addresses select surgical procedures for the prevention or treatment of lymphedema in the upper and lower extremities. Lymphedema is the abnormal accumulation of fluid in the body tissues that results from the disruption of lymphatic drainage. Lymphedema can result in pain, recurrent infections, and functional impairment. The surgical procedures in this document are proposed to treat lymphedema by increasing the function of the lymphatic system. This document does not address lipectomy or liposuction. 

Note: Not Medically Necessary services (as opposed to Investigational and Not Medically Necessary) may be subject to the Women’s Health and Cancer Rights Act of 1998 (WHCRA). Note also that some states have enacted legislation similar to WHCRA and some have expanded upon WHCRA. 

Note: For more information on related topics, please see the following:

  • ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
  • MED.00105 Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
  • SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Position Statement

Investigational and Not Medically Necessary:

Microsurgery for the prevention or treatment of lymphedema (including lymphedema as a result of a mastectomy) is considered investigational and not medically necessary, including but not limited to the following:

  1. Lymphaticolymphatic bypass
  2. Lymphovenous bypass
  3. Lymphaticovenular anastomosis
  4. Vascularized lymph node transfer
  5. Tissue/Flap transfer (for example, omental flap transfer).

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