Lymphedema - Surgical Treatment Form

1 Lymphedema - Surgical Treatment - Medical Policy Updated Revision Effective: June 1, 2025 Policy Number: UM975POL Approval Date: Line(s) of Business: Commercial Medicare Advantage Medicaid (BeHealthy) Description Lymphedema is an accumulation of fluid due to disruption of lymphatic drainage. 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). 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 magnetic resonance imaging, computed tomography, ultrasound, or lymphoscintigraphy, may be used to differentiate lymphedema from others causes of edema in diagnostically challenging cases. Breast cancer treatment is one of the most common causes of secondary lymphedema. Both the surgical removal of lymph nodes and radiotherapy are associated with development of lymphedema in patients with breast cancer. Non-surgical management of lymphedema includes:
Conservative therapy that entails education 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 consisting of repeated application of padding, bandages or compression garments. Manual lymphatic drainage, which is a light pressure massage performed by trained physical therapists or by patients.
Complete decongestive therapy, which is a multiphase treatment program involving all of the previously mentioned non-surgical treatment components at different intensities.
Pneumatic compression pumps, which is 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. 3/11/2025

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There is no cure for lymphedema. However, physiologic microsurgical techniques such as lymphaticovenular anastomosis or vascularized lymph node transfer have been developed that may improve lymphatic circulation, thereby decreasing symptoms and risk of infection.

 Line of Business

Commercial:

 Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:

 Refer to criteria under the Policy section in this medical policy.

 There are no MassHealth guidelines for the surgical procedures for the treatment of Lymphedema listed in this policy.

Medicare:

 Refer to criteria under the Policy section in this medical policy.

 Medicare does not have a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for the surgical procedures listed in this policy.

Policy

I. HNE considers lymphatic physiologic microsurgery EXPERIMENTAL and INVESTIGATIONAL for ALL of the following indications:

A. To TREAT lymphedema including, but not limited to, lymphaticolymphatic bypass, lymphovenous bypass, lymphaticovenous anastomosis, autologous lymph node transplantation, and vascularized lymph node transfer.

B. To PREVENT lymphedema during nodal dissection or breast reconstruction including, but not limited to, the lymphatic microsurgical preventing healing approach.

II. Excisional procedures such as debulking and liposuction/lipectomy to treat lymphedema are considered EXPERIMENTAL and INVESTIGATIONAL.

III. Tissue transfers such as an omental flap to treat lymphedema are considered INVESTIGATIONAL.

IV. Reverse lymphatic mapping used as part of lymphatic surgical or liposuction procedures is considered INVESTIGATIONAL.

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Policy Guidelines and Definitions

Definitions:

Lymphovenous bypass or lymphaticovenular anastomosis: It is a new technique that requires identification of patent, residual lymphatic channels and performing an anastomosis to a recipient venule, thereby allowing outflow of lymphatic fluid and improvement in a patient's lymphedema.

Vascularized lymph node transplant or Lymph node transfer (LNT) or Autologous lymph node transfer (ALNT):
It is an advanced microsurgical treatment for lymphedema. It involves removing lymph nodes from other areas of the body into areas where lymph nodes are absent due to cancer treatment. The new lymph nodes help improve the flow of lymph fluid and reduce lymphedema swelling, tightness and pain.

Lymphatic microsurgical preventive healing approach or LYMPHA: It is a surgical procedure performed at the time of lymph node dissection with the goal of preventing lymphedema in high-risk patients.

Liposuction/Lipectomy: A procedure that uses vacuum suction to remove subcutaneous adipose tissue in certain anatomical areas.

Debulking procedure surgery: It involves removing all the damaged skin and fat down to the muscle and resurfacing the area with a thin shaving of skin from another area of the body, called a skin graft. This is an extreme measure that may be used only for the most advanced cases of lymphedema.

Microsurgical tissue transfer: These procedures involve transfer of composite tissues containing skin and fat from areas with excess tissues (e.g., abdomen) to replace damaged or surgically resected tissues by reconnecting the arterial and venous vessels using microsurgery. Although the lymphatic vessels are not re- anastomosed, tissue edema spontaneously resolves over a period of 6–8 weeks, implying that lymphatic regeneration has occurred.

Omental flap: It is a well-established pedicled flap for coverage of intra-abdominal and thoracic pathology, and as a free-flap for a multitude of applications. Its use as a pedicled flap for extra-abdominal applications other than those on the chest is less well described.

Reverse lymphatic mapping: It is a logical method that guides flap dissection based on physiologic drainage pathways of the trunk and extremity. This technique may minimize the risk of donor-site lymphedema and facilitates flap harvest, although long-term studies are needed to properly assess outcomes.

Coding Guidance

There is no specific code for lymphatic physiologic microsurgery; the following codes may apply. This is not an all-inclusive list.

Code
Description
PA 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy Yes 15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh Yes

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Code
Description
PA 15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg Yes 15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip Yes 15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock Yes 15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm Yes 15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand Yes 15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad Yes 15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area Yes 15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) Yes 15876 Suction assisted lipectomy; head and neck Yes 15877 Suction assisted lipectomy; trunk Yes 15777
Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (i.e., breast, trunk) (List separately in addition to code for primary procedure) No 15878 Suction assisted lipectomy; upper extremity Yes 15879 Suction assisted lipectomy; lower extremity Yes 38308
Lymphangiotomy or other operations on lymphatic channels No 38999
Unlisted procedure, hemic or lymphatic system Yes when associated with procedures listed in this policy.
49906 Free omental flap with microvascular anastomosis No. Considered E&I when used for treatment of Lymphedema.

CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

O'Donnell TF Jr, Allison GM, Iafrati MD. A systematic review of guidelines for lymphedema and the need for contemporary intersocietal guidelines for the management of lymphedema. J Vasc Surg Venous Lymphat Disord. 2020 Jul;8(4):676-684. doi:10.1016/j.jvsv.2020.03.006. Epub 2020 May 20. PMID: 32444277.

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Tidhar, Dorit Armer, Jane M. Stewart, Bob R. What Is Clinically Important in Lymphedema Management? A Systematic Review. Rehabilitation Oncology 36(1):p 13-27, January 2018. | DOI:10.1097/01.REO.0000000000000093.

Schwarz GS, Grobmyer SR, Djohan RS, Cakmakoglu C, Bernard SL, Radford D, Al-Hilli Z, Knackstedt R, Djohan M, Valente SA. Axillary reverse mapping and lymphaticovenous bypass: Lymphedema prevention through enhanced lymphatic visualization and restoration of flow. J Surg Oncol. 2019 Aug;120(2):160-167. doi: 10.1002/jso.25513. Epub 2019 May 29. PMID: 31144329.

Johnson AR, Fleishman A, Granoff MD, Shillue K, Houlihan MJ, Sharma R, Kansal KJ, Teller P, James TA, Lee BT, Singhal D. Evaluating the Impact of Immediate Lymphatic Reconstruction for the Surgical Prevention of Lymphedema. Plast Reconstr Surg. 2021 Mar 1;147(3):373e-381e. doi: 10.1097/PRS.0000000000007636. PMID:

33620920. Coriddi M, Dayan J, Bloomfield E, McGrath L, Diwan R, Monge J, Gutierrez J, Brown S, Boe L, Mehrara B. Efficacy of Immediate Lymphatic Reconstruction to Decrease Incidence of Breast Cancer-related Lymphedema: Preliminary Results of Randomized Controlled Trial. Ann Surg. 2023 Oct 1;278(4):630-637. doi: 10.1097/SLA.0000000000005952. Epub 2023 Jun 14. PMID: 37314177; PMCID: PMC10527595.

          Lynn JV, Hespe GE, Akhter MF, David CM, Kung TA, Myers PL. Cross-Sectional Analysis of Insurance Coverage for Lymphedema Treatments in the United States. JAMA Surg. 2023 Sep 1;158(9):920-926. doi: 10.1001/jamasurg.2023.2017. PMID: 37285151; PMCID: PMC10248808.

          Liposuction in cancer-related lower extremity lymphedema: an investigative study on clinical applications. World J Surg Oncol. 2022 Jan 5;20:6. doi: 10.1186/s12957-021-02472-3. PMID: 34986860; PMCID: PMC8729041.

          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. 2021 Apr 1;147(4):975-993

          International Society of Lymphology Executive Committee. The Diagnosis and Treatment of Peripheral Lymphedema: 2016 Consensus Document of the International Society of Lymphology. 2016

          https://journals.uair.arizona.edu/index.php/lymph/article/view/20106

          Accessed September 5, 2018

          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):500-515. PMID 2354056

          National Lymphedema Network Medical Advisory Committee. The Diagnosis and Treatment of Lymphedema. Position Statement of the National Lymphedema Network 2011; Available at:

          https://lymphnet.org/position-papers

          Accessed February 2019

          Mechanisms of Lymphatic Regeneration after Tissue Transfer

          https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3040774/

          Pedicled omentum for coverage of extra-abdominal vascular bypass graft in the groin

          https://parjournal.net/article/view/2900

          Reverse Lymphatic Mapping: A New Technique for Maximizing Safety in Vascularized Lymph Node Transfer

          https://pubmed.ncbi.nlm.nih.gov/25285683/

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Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 8/2023 Initial Policy Date
1/1/2024 Added Line of Business section 4/2024 Reviewed with no changes 02/2025 Minor Criteria Changes References updated Codes 15830-15877 added for “Excision, excessive skin and subcutaneous tissue” that also includes lipectomy, which is relevant to this policy.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.