043 Form

Medical Policy Liposuction for Lipedema and Lymphedema

Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 043 BCBSA Reference Number: 7.01.169 (For Plan internal use only) NCD/LCD: N/A Related Policies
Bioimpedance Devices for Detection and Management of Lymphedema, #261 Compression Pumps for Treatment of Lymphedema and Venous Ulcers, #354 Surgical Treatments for Lymphedema, #037
Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Lipedema Lipectomy or liposuction is considered MEDICALLY NECESSARY in individuals with documented lipedema when ALL of the following criteria are met (1 through 7):

1. A diagnosis of lipedema has been documented, including ALL of the following: a. Bilateral and symmetrical manifestation with minimal involvement of the feet, unless concomitant lymphedema is present; AND b. Disproportionate adipocyte hypertrophy of the affected extremity; AND c. Photographs of the area to be treated documenting disproportional adipose distribution consistent with diagnosis; AND d. Pressure-induced pain and tenderness on palpation; AND e. Failure of the limb adipose hypertrophy to respond to recommended medically supervised weight loss modalities or bariatric surgery, in concomitant class II or III obesity; AND f. Extent of fibrotic tissue, if present, is expected to be amenable to liposuction; AND
2. Signs and symptoms have not responded to at least 3 consecutive months of optimal conservative medical management, including one or more of the following: a. Compression garments; OR b. Manual therapy; OR c. Conservative management is not feasible due to the presence of contraindicating complications (eg, active infection); AND
3. For each anatomical region being considered for treatment, EITHER of the following criteria are met:

a. There is documented significant functional impairment as a direct result of change in limb volume from lipedema; OR b. There are documented medical complication(s) as a result of lipedema (eg, severe aching discomfort, pain or tenderness, severe maceration, severe recurrent skin infection, or severe venous insufficiency); AND

4. Lipectomy or liposuction is reasonably expected to improve the functional impairment or medical complications; AND
5. The plan of care includes the use of compression garments as instructed and to continue conservative treatment postoperatively to maintain benefits; AND
6. Photographic documentation is consistent with the diagnosis of lipedema in the affected extremities, including limb symmetry; AND

7. Surgical treatment is performed by a hospital credentialed, board-certified plastic surgeon experienced in the treatment of lipedema.

   Lymphedema

   Lipectomy or liposuction is considered MEDICALLY NECESSARY in individuals with documented lymphedema when ALL of the following criteria are met (1 through 6):

8. Signs and symptoms have not responded to at least 3 consecutive months of optimal conservative medical management, including ONE OR MORE of the following: a. Compression garments; OR b. Manual lymphatic drainage; OR c. Complex/complete decongestive therapy (CDT); OR d. Conservative management is not feasible due to the presence of contraindicating complications (eg, active infection); AND
9. For each anatomical region being considered for treatment, EITHER of the following criteria are met: a. There is documented significant functional impairment as a direct result of change in limb volume; OR b. There are documented medical complication(s) as a result of lymphedema (eg, severe recurrent infection or neurological dysfunction); AND
10. Lipectomy or liposuction is reasonably expected to improve the functional impairment; AND
11. The plan of care includes the use of compression garments as instructed and to continue conservative treatment postoperatively to maintain benefits; AND
12. Photographic documentation is consistent with the diagnosis of lymphedema in the affected extremities, including limb asymmetry; AND

13. Surgical treatment is performed at a center of excellence by a hospital credentialed, board-certified plastic surgeon experienced in the treatment of lymphedema.

    Lipectomy or liposuction is considered INVESTIGATIONAL for the treatment of lymphedema or lipedema in all other situations where the above criteria are not met.

    Policy Guidelines Medically necessary positions are based on clinical input. Some patients with lipedema may present with concomitant lymphedema. As a result, these patients may not have a negative Stemmer sign or absence of pitting edema.

    Liposuction for lipedema may need to be completed in stages when the total volume of liposuction exceeds the clinical standard of 5000cc total aspirate during the initial procedure. Repeat procedures may also need to be considered on an individual basis as surgical intervention, including liposuction, is not considered curative. Correction of lymphedema (for example, related to surgical mastectomy or lymph node dissection) or lipedema using lipectomy or liposuction is considered reconstructive when done to address a significant variation from normal. Advanced disease may present with significant fibrotic tissue; in such cases, debulking surgery may yield better outcomes and liposuction may be less feasible. Indocyanine green (ICG) lymphography is an imaging method that can assess lymphatic flow across the anatomy and guide liposuction treatment planning, prioritizing preservation of functioning lymphatics.

*Per the Centers for Disease Control and Prevention (CDC), obesity is classified as follows:
Class 1: BMI of 30 to < 35 kg/m2
Class 2: BMI of 35 to < 40 kg/m2kg/m2 or higher
Class 3: BMI <40 kg/m2

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is required. Commercial PPO and Indemnity Prior authorization is required. Medicare HMO BlueSM Prior authorization is required. Medicare PPO BlueSM Prior authorization is required.

CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes: CPT codes: Code Description 15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh 15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg 15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip 15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock 15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm 15878 Suction assisted lipectomy; upper extremity 15879 Suction assisted lipectomy; lower extremity

According to the policy statement above, the following CPT codes are considered investigational for the conditions listed for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes:
CPT codes: Code Description 15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand

15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad 15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area 15876 Suction assisted lipectomy; head and neck 15877 Suction assisted lipectomy; trunk

Description Lipedema Lipedema, also known as lipoedema, is a rare disorder characterized by a large amount of subcutaneous fat in the extremities. The cause is unknown but is most frequently seen in women with a family history. The exact prevalence is uncertain as it does not have a diagnosis in the International Classification of Diseases (ICD-10). Lipedema is often misdiagnosed as obesity or lymphedema. Lipedema is typically observed in the legs and thighs without affecting the feet, and the adipose tissue is painful. The arms may also be affected without edema of the hands. Symptoms include heaviness, pain (particularly with pressure), loss of strength, easy bruising, and a reduction in daily activity levels that affects the health and quality of life of the individual. The excessive fat deposits are typically unresponsive to traditional weight loss interventions and there is no cure. Untreated lipedema may result in secondary problems including osteoarthritis and reduced mobility. Over time, the weight of the excessive fat build-up can impair the ability to walk. Initially, the lymphatic system can cope with the increased amount of interstitial fluid, but in the later stages, secondary lymphedema (lipolymphoedema) can occur if the fatty deposits compromise the lymphatic system.

Lymphedema Lymphedema is an accumulation of fluid due to disruption of lymphatic drainage. It is characterized by nonpitting swelling of an extremity or trunk, and is associated with wound healing impairment, recurrent skin infections, and decreased quality of life. Lymphedema can be caused by congenital or inherited abnormalities in the lymphatic system (primary lymphedema) but is most often caused by acquired damage to the lymphatic system (secondary lymphedema). Breast cancer treatment (surgical removal of lymph nodes and radiotherapy) is one of the most common causes of secondary lymphedema. In a systematic review of 72 studies (N=29,612 women), DiSipio et al (2013) reported that nearly 20% of breast cancer survivors will develop arm lymphedema.1, The risk factors with robust evidence for the development of lymphedema included extensive surgical procedures (such as axillary lymph node dissection, a higher number of lymph nodes removed, and mastectomy) as well as being overweight or obese. A diagnosis of secondary lymphedema is based on history (e.g., cancer treatment, trauma) and physical examination (localized, progressive edema and asymmetric limb measurements) when other causes of edema can be excluded. Imaging, such as MRI, computed tomography, ultrasound, or lymphoscintigraphy, may be used to differentiate lymphedema from other causes of edema in diagnostically challenging cases. The International Society of Lymphology has provided guidance for staging lymphedema (2023) based on "softness" or "firmness" of the limb and the changes with an elevation of the limb.2,

Notable differences between lipedema and lymphedema are described in Table 1.

Table 1. Characteristics of Lipedema and Lymphedema Characteristics Lipedema Lymphedema Pathophysiology Genetic, primary Defects in lymph vessels, primary or secondary Age of onset Puberty Any age Sex Female Both sexes Involvement Bilateral, mainly legs Unilateral or bilateral, mainly arms and legs Symmetry Symmetric May be asymmetric Disproportion Yes No Involvement of feet or hands No Yes Easy bruising Yes No

Adapted from Schavit et al (2018)3,

Treatment Initial conservative therapy includes exercise and weight loss, compression garments, and manual lymphatic drainage. Complete decongestive therapy involves health professionals who address skin and nail care, therapeutic exercise, manual lymphatic drainage, and limb compression, which is performed daily for 5 days per week. The maintenance phase is intended to conserve the benefit in the first phase and is self-administered. For those who have failed conservative measures, pneumatic compression pumps, and, occasionally, surgery are used as treatment options.

Liposuction has been proposed as a treatment option for both lipedema and lymphedema.

Summary Description Lipedema is a disorder characterized by a large amount of subcutaneous fat in the extremities, typically the legs and thighs. The adipose tissue may be painful. In contrast, lymphedema is the accumulation of interstitial fluid due to impaired lymphatic flow. This increase in interstitial fluid may lead to the accumulation and hypertrophy of fat cells. Liposuction, consisting of the removal of fat cells with a cannula and tumescent anesthesia is being investigated as a treatment option for both lipedema and lymphedema.

Summary of Evidence For individuals with lipedema who receive liposuction, the evidence includes systematic reviews and meta- analyses of observational studies. Relevant outcomes are symptoms, change in disease status, functional outcomes, and quality of life. The latest meta-analysis of 9 studies (N=635 patients) investigating the impact of various liposuction techniques for individuals with lipedema revealed improvements in the quality of life, pain, pressure sensitivity, bruising, cosmetic impairment, heaviness, walking difficulty, and itching among lipedema patients who underwent liposuction. This analysis was based on prospective cohort studies, which introduces a risk of publication bias. Insufficient detail in some reports contributed to potential data inconsistencies. All studies included in the meta-analysis originated from Germany, highlighting a significant geographical bias. The durability of the procedure is uncertain, and no studies were identified that compared liposuction to continued decongestive therapy. To address these limitations, future investigations must prioritize RCTs to assess the safety and efficacy of various liposuction techniques. One such trial is currently in progress and will provide needed information on the benefits and harms of this procedure. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with lymphedema who receive liposuction, the evidence includes systematic reviews, and 1 non-blinded small RCT on submental liposuction for cervical lymphedema following head and neck cancer treatment. Relevant outcomes are symptoms, change in disease status, functional outcomes, and quality of life. The available evidence suggests that arm volume can be reduced by the procedure, but follow-up duration is limited and the studies have a number of other limitations that include lack of blinding, subjective outcome measures, lack of physiotherapy control, and small sample size. The latest systematic review of 12 observational studies (N=487 participants) investigating the impact of various liposuction techniques on treating breast cancer-related lymphedema revealed considerable variability in effect sizes across these studies. Due to the high risk of bias, this body of evidence is considered low quality. No trials were identified that compared liposuction to a decongestive therapy protocol with continued compression. Further study is needed to evaluate the impact of liposuction when compared to a decongestive therapy protocol. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Additional Information 2025 Input Clinical input was sought to help determine whether the use of liposuction for individuals with lipedema or lymphedema would provide a clinically meaningful improvement in net health outcome and represents generally accepted medical practice in selected patients. In response to requests, clinical input was received from 3 respondents identified by the National Commission on Lymphatic Diseases (NCLD) or an

academic medical center. In addition to this request, a plastic surgeon specializing in lymphedema research and reconstruction at a major academic medical center was interviewed.

For individuals with lipedema or lymphedema with progressive disease who failed to respond to conservative therapy, clinical input supports that use of liposuction is consistent with generally accepted medical practice and its use is expected to provide a clinically meaningful improvement in the net health outcome.

Policy History Date Action 12/2025 Policy revised. Policy updated with literature review through June 16, 2025. Association policy statements and criteria adopted. Association policy statements revised to be medically necessary with criteria following review of clinical input. Effective 12/1/2025. 4/2025 Policy clarified to remove reference to the diagnosis of lipedema in the trunk. 4/15/25.
5/2024 New medical policy describing ongoing medically necessary and investigational indications. 5/1/2024.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. DiSipio T, Rye S, Newman B, et al. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. May 2013; 14(6): 500-15. PMID 23540561
2. International Society of Lymphology Executive Committee. The Diagnosis and Treatment of Peripheral Lymphedema: 2023 Consensus Document of the International Society of Lymphology. 2023; https://journals.librarypublishing.arizona.edu/lymph/article/id/6372/. Accessed November 23, 2024.
3. Shavit E, Wollina U, Alavi A. Lipoedema is not lymphoedema: A review of current literature. Int Wound J. Dec 2018; 15(6): 921-928. PMID 29956468
4. Chia CT, Neinstein RM, Theodorou SJ. Evidence-Based Medicine: Liposuction. Plast Reconstr Surg. Jan 2017; 139(1): 267e-274e. PMID 28027260
5. Araco A, Gravante G, Araco F, et al. Comparison of power water--assisted and traditional liposuction: a prospective randomized trial of postoperative pain. Aesthetic Plast Surg. 2007; 31(3): 259-65. PMID 17380360
6. Peprah K, MacDougall D. Liposuction for the treatment of lipedema: A review of clinical effectiveness and guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health. Jun 7, 2019. https://www.ncbi.nlm.nih.gov/books/NBK545818/pdf/Bookshelf_NBK545818.pdf PMID: 31479212
7. Mortada H, Alaqil S, Jabbar IA, et al. Safety and Effectiveness of Liposuction Modalities in Managing Lipedema: Systematic Review and Meta-analysis. Arch Plast Surg. Sep 2024; 51(5): 510-526. PMID 39345998
8. Podda M, Kovacs M, Hellmich M, et al. A randomised controlled multicentre investigator-blinded clinical trial comparing efficacy and safety of surgery versus complex physical decongestive therapy for lipedema (LIPLEG). Trials. Oct 30 2021; 22(1): 758. PMID 34717741
9. Fijany AJ, Ford AL, Assi PE, et al. Comparing the safety and effectiveness of different liposuction techniques for lipedema. J Plast Reconstr Aesthet Surg. Oct 2024; 97: 256-267. PMID 39173577
10. Chang DW, Dayan J, Greene AK, et al. Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference. Plast Reconstr Surg. Apr 01 2021; 147(4): 975-993. PMID 33761519

11. Forte AJ, Huayllani MT, Boczar D, et al. Lipoaspiration for the Treatment of Lower Limb Lymphedema: A Comprehensive Systematic Review. Cureus. Oct 15 2019; 11(10): e5913. PMID 31754590
12. Lilja C, Madsen CB, Damsgaard TE, et al. Surgical treatment algorithm for breast cancer lymphedema- a systematic review. Gland Surg. May 30 2024; 13(5): 722-748. PMID 38845835
13. Alamoudi U, Taylor B, MacKay C, et al. Submental liposuction for the management of lymphedema following head and neck cancer treatment: a randomized controlled trial. J Otolaryngol Head Neck Surg. Mar 26 2018; 47(1): 22. PMID 29580298
14. Executive Committee of the International Society of Lymphology. The Diagnosis and Treatment of Peripheral Lymphedema: 2023 Consensus Document of The International Society of Lymphology. Lymphology. 2023; 56(4): 133-151. PMID 39207406
15. Sandhofer M, Hanke CW, Habbema L, et al. Prevention of Progression of Lipedema With Liposuction Using Tumescent Local Anesthesia: Results of an International Consensus Conference. Dermatol Surg. Feb 2020; 46(2): 220-228. PMID 31356433
16. National Institute for Health and Care Excellence (NICE). Liposuction for chronic lymphoedema. Interventional procedures guidance. IPG723. 2022. https://www.nice.org.uk/guidance/ipg723. Accessed November 26, 2024.
17. National Institute for Health and Care Excellence (NICE). Liposuction for chronic lipoedema. Interventional procedures guidance. IPG721. 2022. https://www.nice.org.uk/guidance/ipg723. Accessed November 25, 2024.