Humana Commercial Clinical Policy

Humana Lymphedema (Diagnosis and Treatment) Form

Effective Date

05/25/2023

Last Reviewed

NA

Original Document

  Reference



Description

Lymphedema is swelling caused by an abnormal collection of fluid beneath the skin resulting from lymph vessel impairment or lymph node removal. It is generally categorized as primary or secondary; primary is caused by problems with the development of lymph vessels, while secondary is related to something that has damaged the lymph nodes or vessels (eg, surgery, radiation, cancer, infection). Lymphedema differs from edema which is swelling caused by excess fluid that becomes trapped in the body’s tissues as a result of medication, pregnancy or underlying disease (eg, heart failure, venous insufficiency, kidney disease, cirrhosis of the liver).

Diagnosis

Assessment and monitoring of lymphedema can be accomplished by a number of methods. One of the most common is circumferential measurement of limb volume.

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Lymphedema – Diagnosis and Treatment

Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0432-032
Page: 2 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

The volume is calculated with measurements obtained with a tape measure at various locations on the limb; it may be compared to measurements of the opposite limb. Another method is the water displacement measurement. The limb is submerged into a container of water and the amount that is displaced is measured.

Bioimpedance spectroscopy (BIS), also referred to as bioelectrical impedance analysis, has been proposed as an alternative method to diagnose/monitor lymphedema. This device measures the impedance (resistance) of electrical current through extracellular fluid via electrodes that have been attached to the wrist when testing the arm or the ankle when testing the leg. A mild electrical current is passed through the electrode and a measurement of the resistance of the current flow through the fluid is obtained. An example of this device is the L-Dex. (Refer to Coverage Limitations section)

For information regarding bioelectrical impedance analysis (BIA) for body composition, please refer to Code Compendium (Miscellaneous) Medical Coverage Policy.

Treatment

Treatment of lymphedema may be undertaken by a number of methods, either alone or in combination, including, but not limited to, the use of lymphedema garments, manual lymph drainage massage, lymphedema pumps and/or surgery.

Lymphedema garments (also referred to as compression garments), which include sleeves, gloves and stockings, are special bandages that can be worn on the arms, legs, hands or feet to help reduce swelling that is caused by the removal or injury of nearby lymphatic vessels or nodes. The garments provide specific amounts of pressure to keep the fluid from accumulating in the limb. (For more specific information about over-the-counter [OTC] or ready-made garments, please refer to Coverage Limitations section and/or Support Garments, Fabric Medical Coverage Policy).

Manual lymph drainage massage (also known as complex decongestive physiotherapy or complete decongestive physiotherapy) may be performed by a physical therapist or occupational therapist certified in manual lymph drainage. This technique combines massage, bandaging, exercise and skin care in an attempt to reduce the accumulation of fluid.

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Lymphedema pumps (pneumatic compression pumps) are devices that use compressed air to apply pressure to a limb in order to move excess lymph fluid into the rest of the body. A unicompartmental (nonsegmented) device consists of a rubberized sleeve or boot with a single inflatable chamber that exerts uniform pressure along the affected limb. A multicompartmental (segmented) device has multiple chambers in the rubberized sleeve or boot that inflate and deflate in a sequential fashion. These devices may be controlled either with or without manual control of the amount of pressure used in the compartments (manual control is also known as gradient pressure).

An advanced multicompartmental programmable pneumatic compression device (formerly referred to as a two-stage multichamber programmable pneumatic compression device) operates similar to the principles of manual lymph drainage (treat the proximal areas first, which is theorized to prepare the distal areas for drainage). Examples of this type of pump include, but may not be limited to, the AIROS 6, AIROS 8, Flexitouch (Flexitouch Plus) or Lympha Press Optimal (Lympha Press Optimal Plus).

A variation of the multicompartmental pneumatic compression pump is the CircuFlow 5200 Sequential Compression Device, which combines intermittent pneumatic compression with a sustained gradient pressure. (Refer to Coverage Limitations section)

A new device has been proposed as an alternative treatment for lymphedema, the Dayspring Limb Compression System, which unlike pneumatic compression pumps, does not use air to produce the compression, but rather uses a nickel-titanium shape-memory alloy to apply sequential gradient compression. The device is wearable (portable), programmable and battery powered, consisting of the controller and a garment (limb sleeve). It may also be referred to as a nonpneumatic compression controller. (Refer to Coverage Limitations section)

This policy ONLY addresses treatment for lymphedema. For information regarding other uses of pneumatic compression pumps (eg, chronic venous insufficiency, deep vein thrombosis [DVT] prevention), please refer to Pneumatic Compression Pumps Medical Coverage Policy.

Lymphedema – Diagnosis and Treatment
Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0432-032
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Surgery, though not curative and rarely performed, has been suggested as a treatment for those with refractory lymphedema who have not improved with conservative management. Lymphedema surgery may be classified as reconstructive or excisional. Excisional surgical procedures for lymphedema include, but may not be limited to, debulking and liposuction. Reconstructive surgical procedures include, but may not be limited to, microsurgical treatment (eg, microsurgical lymphatico-venous anastomosis, lymphatic-capsular-venous anastomosis, lymphovenous bypass), lymph node transfer (also known as vascularized lymph node transfer) and tissue transfers (eg, omental flap). (Refer to Coverage Limitations section)

Coverage

Compression (Lymphedema) Garments

Compression (Lymphedema) Garments Humana members may be eligible under the Plan for custom-made compression (lymphedema) garments for the extremities (eg, gloves, sleeves or stockings) for the treatment of primary or secondary lymphedema.

Coverage Determination

Two sets of lymphedema garments per affected extremity are allowed initially; 1 set per affected extremity may be covered thereafter in a rolling 12 month period.

  • (Sleeves and gloves are separate items; as such, if both should be required for treatment, 2 gloves and 2 sleeves would be allowed initially, with 1 additional of each in subsequent years, if needed. )

A rolling 12 month period is 12 months after an event, regardless of what month the initial event took place; eg, the initial sets of garments are provided on May 1, 2023, the rolling 12 month period would end on April 30, 2024; in this example, no additional garments would be authorized until May 1, 2024.

Manual Lymph Drainage Massage

Humana members may be eligible under the Plan for manual lymph drainage massage (also known as complex or complete decongestive physiotherapy) for the treatment of primary or secondary lymphedema when the following criteria are met:

  • Individual has undergone a 4 week trial of conservative treatment, including compression garments, elevation of the affected limb and home exercises; AND
  • The treating healthcare provider determines there has been no improvement or symptoms remain; AND
  • Submission of clinical records documenting the individual's adherence to the conservative treatment that was tried and failed; AND
  • Treatment is performed by a physical therapist or occupational therapist, preferably certified in manual lymph drainage

This treatment may be applied toward the number of allowable visits of the physical therapy benefit. Refer to specific certificate language regarding physical medicine and rehabilitation services. Most certificates limit the duration or number of visits.

Lymphedema Pumps (Pneumatic Compression Pumps)

Humana members may be eligible under the Plan for the following types of pneumatic compression pumps for the treatment of primary or secondary lymphedema of the extremities (arms or legs) when the following criteria are met:

  • Initial approval, if criteria are met, is limited to a maximum of 90 days; AND
  • Unicompartmental (nonsegmented) or multicompartmental (segmented) lymphedema pump WITHOUT gradient pressure (manual control of the pressure in the chamber) (E0650, E0651) of the pressure in the chamber for home use for the treatment of lymphedema when the following are met:
    • Individual has undergone a 4 week trial of conservative therapy, including the use of an appropriate compression garment, exercise and elevation; AND
    • The treating healthcare provider determines there has been no improvement or symptoms remain; AND
    • Submission of clinical records documenting the individual’s adherence to the conservative therapy that was tried and failed; OR

Lymphedema – Diagnosis and Treatment
Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0432-032
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

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  • Unicompartmental (nonsegmented) or multicompartmental (segmented) lymphedema pump WITH gradient pressure (manual control of the pressure) (E0652)** (manual control of the pressure) when ALL of the following criteria are met:
    1. Individual has undergone a 4 week trial of a unicompartmental or multicompartmental lymphedema pump without manual control of the pressure in each chamber; AND
    2. Lymphedema extends from the extremities onto the chest, abdomen or trunk; AND
    3. The treating healthcare provider determines that there has been no improvement or symptoms remain; AND
    4. Submission of clinical documentation of compliance and adherence with use of the unicompartmental or multicompartmental pump without control of the pressure in each chamber as per the healthcare provider's instructions/prescription**This includes the advanced multicompartmental programmable pumps (eg, AIROS 6, AIROS 8, Flexitouch [Flexitouch Plus] or Lympha Press Optimal [Lympha Press Optimal Plus]) which are considered equally effective to standard segmented pneumatic compression pumps.
Continuation of Coverage

Lymphedema pumps are initially authorized for 90 days. Continued authorization is dependent upon clinical documentation, submitted by the prescribing healthcare provider, which demonstrates the following:

  • Adherence with the use of the device as per the healthcare provider's instructions/prescription; AND
  • Confirmation of clinical benefit (eg, improvement in, or prevention in worsening of, the condition for which the device was prescribed)

Lymphedema – Diagnosis and Treatment
Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0432-032
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Coverage Limitations

Humana members may NOT be eligible under the Plan for compression (lymphedema) garments, manual lymph drainage massage or lymphedema pumps for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for any other treatment method not listed above including, but may not be limited to:

  • Compression garments for the chest, head, neck or trunk; OR
  • Immediate lymphatic reconstruction surgery for prevention of breast cancer-related lymphedema; OR
  • Lymphedema pump (and the associated appliance) for treatment of lymphedema isolated to the chest or trunk; OR
  • Lymphedema pump (and the associated appliance) for treatment of lymphedema to the head or neck; OR
  • Surgical treatment of lymphedema including, but may not be limited to:
    • Excisional procedures (eg, debulking, liposuction); OR
    • Lymph node transfer (also known as vascularized lymph node transfer); OR
    • Microsurgical treatment (eg, lymphatico-venous anastomosis, lymphatic-capsular-venous anastomosis, lymphovenous bypass); OR

Lymphedema – Diagnosis and Treatment
Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0432-032
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Tissue transfer (eg, omental flap) These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for pumps/devices with a sustained gradient pressure while also delivering a higher intermittent pneumatic compression including, but not limited to, the CircuFlow 5200 Sequential Compression Device for any indication. These are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for the Dayspring nonpneumatic compression system controller (with or without sequential calibrated gradient pressure) or garments for any indication. These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for the use of bioimpedance spectroscopy including, but not limited to, the L-Dex for diagnosing, monitoring or pre- or postoperative assessment of lymphedema. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for ready-made (prefabricated) compression garments/stockings for any indication. Although they may be prescribed by a health care practitioner, ready-made compression garments/stockings are also available without a prescription and may be obtained over-the-counter (OTC) and are therefore generally excluded in the certificate. In the absence of a certificate exclusion for OTC items, ready-made compression garments/stockings are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Lymphedema – Diagnosis and Treatment
Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0432-032
Page: 9 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Additional information about lymphatic system and lymphedema may be found from the following websites:

  • American Cancer Society
  • National Cancer Institute
  • National Library of Medicine

Medical Alternatives

Alternatives to bioimpedance spectroscopy include, but may not be limited to, the following:

  • Circumferential measurement
  • Water displacement

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

CPT® Code(s)

  • 38308 - Lymphangiotomy or other operations on lymphatic channels. Not Covered if used to report surgical treatment of lymphedema
  • 93702 - Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s). Not Covered
  • 97016 - Application of a modality to 1 or more areas; vasopneumatic devices

Lymphedema – Diagnosis and Treatment
Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0432-032
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

97140

  • Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

HCPCS Code(s)

  • A6549 - Gradient compression stocking/sleeve, not otherwise specified. Not Covered if used to report ready-made (prefabricated) compression garments/stockings (ie, Over the counter)
  • E0650 - Pneumatic compressor, nonsegmental home model
  • E0651 - Pneumatic compressor, segmental home model without calibrated gradient pressure
  • E0652 - Pneumatic compressor, segmental home model with calibrated gradient pressure. Not Covered if used to report any pump/device outlined in Coverage Limitations section
  • E0655 - Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm
  • E0656 - Segmental pneumatic appliance for use with pneumatic compressor, trunk. Not Covered
  • E0657 - Segmental pneumatic appliance for use with pneumatic compressor, chest. Not Covered
  • E0660 - Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg
  • E0665 - Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm
  • E0666 - Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg

Lymphedema – Diagnosis and Treatment
Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0432-032
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E0667

  • Segmental pneumatic appliance for use with pneumatic compressor, full leg. Not Covered if used to report any pump/device outlined in Coverage Limitations section
  • E0668 - Segmental pneumatic appliance for use with pneumatic compressor, full arm. Not Covered if used to report any pump/device outlined in Coverage Limitations section
  • E0669 - Segmental pneumatic appliance for use with pneumatic compressor, half leg. Not Covered if used to report any pump/device outlined in Coverage Limitations section
  • E0670 - Segmenta pneumatic appliance for use with pneumatic compressor, integrated, two full legs and trunk. Not Covered
  • E0671 - Segmental gradient pressure pneumatic appliance, full leg. Not Covered if used to report any pump/device outlined in Coverage Limitations section
  • E0673 - Segmental gradient pressure pneumatic appliance, full arm. Not Covered if used to report any pump/device outlined in Coverage Limitations section
  • E0676 - Intermittent limb compression device (includes all accessories), not otherwise specified
  • E0677 - Non-pneumatic sequential compression garment, trunk. Not Covered New Code Effective 04/01/2023

Lymphedema – Diagnosis and Treatment
Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0432-032
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • E1399 - Durable medical equipment, miscellaneous. Not Covered if used to report any treatments outlined in Coverage Limitations section
  • K1024 - Nonpneumatic compression controller with sequential calibrated gradient pressure. Not Covered
  • K1025 - Nonpneumatic sequential compression garment, full arm. Not Covered
  • K1031 - Non-pneumatic compression controller without calibrated gradient pressure. Not Covered
  • K1032 - Non-pneumatic sequential compression garment, full leg. Not Covered
  • K1033 - Non-pneumatic sequential compression garment, half leg. Not Covered
  • L8010 - Breast prosthesis, mastectomy sleeve
  • S8420 - Gradient pressure aid (sleeve and glove combination), custom made
  • S8422 - Gradient pressure aid (sleeve), custom made, medium weight
  • S8423 - Gradient pressure aid (sleeve), custom made, heavy weight
  • S8425 - Gradient pressure aid (glove), custom made, medium weight
  • S8426 - Gradient pressure aid (glove), custom made, heavy weight
  • S8429 - Gradient pressure exterior wrap

References

  • Agency for Healthcare Research and Quality (AHRQ). Technology Assessment (ARCHIVED). Diagnosis and treatment of secondary lymphedema. https://www.ahrq.gov. Published May 28, 2010. Accessed May 8, 2023.
  • American Cancer Society (ACS). American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline. https://www.cancer.org. Published 2016. Accessed May 12, 2023.
  • American Cancer Society (ACS). American Cancer Society head and neck cancer survivorship care guideline. https://www.cancer.org. Published 2016.
  • American Society of Clinical Oncology (ASCO). Integrative therapies during and after breast cancer treatment: ASCO endorsement of the SIO clinical practice guideline. https://www.asco.org. Published September 2018. Accessed May 12, 2023.
  • American Vein & Lymphatic Society (AVLS). Selecting appropriate compression for lymphedema patients. https://www.myavls.org. Published 2023. Accessed May 12, 2023.
  • American Venous Forum. The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment. https://www.venousformum.org. Published 2022. Accessed May 12, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Pneumatic compression devices (280.6). https://www.cms.gov. Published January 14, 2002. Accessed May 12, 2023.
  • ECRI Institute. Clinical Evidence Assessment. Dayspring Limb Compression System (Koya Medical) for treating lymphedema. https://www.ecri.org. Published August 18, 2021. Accessed April 25, 2023.
  • ECRI Institute. Clinical Evidence Assessment. Lympha Press Optimal Plus Pump (Mego Afek AC Ltd.) for treating lymphedema. https://www.ecri.org. Published February 24, 2022. Accessed April 25, 2023.
  • ECRI Institute. Clinical Evidence Assessment. Lymphatic microsurgical preventive healing approach (LYMPHA) for preventing lymphedema. https://www.ecri.org. Published June 16, 2020. Accessed April 25, 2023.
  • ECRI Institute. Clinical Evidence Assessment. SOZO Bioimpedance Spectroscopy (ImpediMed, Inc.) for diagnosing and managing lymphedema. https://www.ecri.org. Published May 12, 2020. Accessed April 25, 2023.
  • ECRI Institute. Evidence Report. Complex decongestive therapy for secondary lymphedema. https://www.ecri.org. Published November 2, 2012. Accessed April 25, 2023.
  • ECRI Institute. Hotline Response. Near-infrared fluorescence lymphatic imaging for diagnosing lymphedema. https://www.ecri.org. Published April 16, 2020. Accessed April 25, 2023.
  • ECRI Institute. Hotline Response. Near-infrared fluorescence lymphatic imaging for guiding manual lymphatic drainage for lymphedema treatment. https://www.ecri.org. Published April 30, 2020. Accessed April 25, 2023.
  • ECRI Institute. Hotline Response (ARCHIVED). Bioimpedance spectroscopy for assessing lymphedema. https://www.ecri.org. Published July 12, 2010. Updated January 10, 2013. Accessed April 25, 2023.
  • ECRI Institute. Hotline Response (ARCHIVED). Nonelastic compression garments for treatment of lymphedema. https://www.ecri.org. Published February 19, 2010. Accessed December 7, 2012.
  • ECRI Institute. Product Brief (ARCHIVED). Flexitouch System (Tactile Systems Technology, Inc.) for treating lymphedema. https://www.ecri.org. Published December 14, 2012. Updated January 11, 2016. Accessed April 25, 2023.
  • ECRI Institute. Product Brief (ARCHIVED). L-Dex U400 Extracellular Fluid Analyzer (ImpediMed, Ltd.) for aiding detection of lymphedema. https://www.ecri.org. Published July 8, 2015. Accessed April 25, 2023.

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    Lymphedema – Diagnosis and Treatment
    Effective Date: 05/25/2023
    Revision Date: 05/25/2023
    Review Date: 05/25/2023
    Policy Number: HUM-0432-032
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  • MoistureMeterD and MoistureMeterD Compact (Delfin Technologies, Ltd.) for diagnosing lymphedema. https://www.ecri.org. Published July 21, 2015. Accessed April 25, 2023.
  • ECRI Institute. Product Brief (ARCHIVED). Overview of selected analyzers for diagnosing lymphedema. https://www.ecri.org. Published July 31, 2015. Accessed February 25, 2020.
  • Hayes, Inc. Evidence Analysis Research Brief. Dayspring (Koya Medical Inc.) for treatment of lymphedema. https://evidence.hayesinc.com. Published March 27, 2023. Accessed April 24, 2023.

    • Lymphedema – Diagnosis and Treatment
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  • Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). Flexitouch system (Tactile Medical) for lymphedema of the head and neck. https://evidence.hayesinc.com. Published June 17, 2021. Accessed April 24, 2023.
  • Hayes, Inc. Evidence Analysis Research Brief (ARCHIVED). Indocyanine green lymphography for assessment of breast cancer related lymphedema. https://evidence.hayesinc.com. Published May 19, 2021. Accessed April 24, 2023.
  • Hayes, Inc. Evolving Evidence Review. Flexitouch Plus system (Tactile Medical) for lymphedema of the head and neck. https://evidence.hayesinc.com. Published September 29, 2021. Accessed April 24, 2023.
  • Hayes, Inc. Health Technology Assessment. Bioelectrical impedance (bioimpedance) analysis for assessment of lymphedema. https://evidence.hayesinc.com. Published August 6, 2020. Updated March 17, 2023. Accessed April 24, 2023.
  • Hayes, Inc. Health Technology Assessment. Liposuction for the reductive surgical treatment of lymphedema. https://evidence.hayesinc.com. Published October 27, 2020. Updated December 8, 2022. Accessed April 24, 2023.
  • Hayes, Inc. Health Technology Assessment. Lymph tissue transfer for the physiological microsurgical treatment of lymphedema. https://evidence.hayesinc.com. Published August 25, 2020. Updated September 1, 2022. Accessed April 24, 2023.
  • Hayes, Inc. Health Technology Assessment. Lymphovenous anastomosis for the physiological microsurgical treatment of lymphedema. https://evidence.hayesinc.com. Published June 9, 2020. Updated June 24, 2022. Accessed April 24, 2023.
  • Hayes, Inc. Health Technology Assessment. Microsurgery for primary prevention of breast cancer related lymphedema. https://evidence.hayesinc.com. Published October 15, 2019. Updated November 14, 2022. Accessed April 25, 2023.

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  • Hayes, Inc. Health Technology Brief (ARCHIVED). Microsurgery for primary prevention of lymphedema following surgery for breast cancer. https://evidence.hayesinc.com. Published July 16, 2013. Updated June 30, 2015. Accessed April 25, 2023.
  • Hayes, Inc. Health Technology Brief (ARCHIVED). Microsurgical treatment of lymphedema following breast cancer surgery. https://evidence.hayesinc.com. Published July 18, 2013. Updated June 30, 2015. Accessed April 25, 2023.
  • Hayes, Inc. Health Technology Brief (ARCHIVED). Pneumatic compression devices for treatment of peripheral lymphedema. https://evidence.hayesinc.com. Published June 6, 2005. Updated January 7, 2008. Accessed April 24, 2023.
  • Hayes, Inc. Search & Summary (ARCHIVED). Axillary reverse mapping to limit the incidence of breast cancer related lymphedema. https://evidence.hayesinc.com. Published May 18, 2017. Accessed February 25, 2020.
  • Hayes, Inc. Search & Summary (ARCHIVED). Suction-assisted protein lipectomy (SAPL) for treatment of severe lymphedema. https://evidence.hayesinc.com. Published November 6, 2014. Accessed December 6, 2016.

Lymphedema – Diagnosis and Treatment
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Revision Date: 05/25/2023
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  • International Society of Lymphology (ISL). The diagnosis and treatment of peripheral lymphedema: 2020 consensus document of the International Society of Lymphology. https://www.isl.arizona.edu. Published 1995. Updated 2020. Accessed May 12, 2023.
  • MCG Health. Bioimpedance spectroscopy. 26th edition. https://www.mcg.com. Accessed April 6, 2023.
  • MCG Health. Graduated compression stockings. 26th edition. https://www.mcg.com. Accessed April 6, 2023.
  • MCG Health. Intermittent pneumatic compression with extremity pump. 26th edition. https://www.mcg.com. Accessed April 6, 2023.
  • MCG Health. Lymphatic drainage, manual. 26th edition. https://www.mcg.com. Accessed April 6, 2023.
  • National Cancer Institute (NCI). Lymphedema (PDQ) – health professional version. https://www.cancer.gov. Updated March 22, 2023. Accessed May 12, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Breast cancer. https://www.nccn.org. Updated March 23, 2023. Accessed May 12, 2023.
  • National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Survivorship. https://www.nccn.org. Updated March 24, 2023. Accessed May 12, 2023.
  • National Lymphedema Network (NLN). Position Statement of the National Lymphedema Network. Screening and measurement for early detection of breast cancer related lymphedema. https://www.lymphnet.org. Published April 2011. Accessed May 12, 2023.
  • National Lymphedema Network (NLN). Position Statement of the National Lymphedema Network. Training of lymphedema therapists. https://www.lymphnet.org. Published May 2010. Accessed May 12, 2023.

Lymphedema – Diagnosis and Treatment
Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0432-032
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  • UpToDate, Inc. Breast cancer-associated lymphedema. https://www.uptodate.com. Updated April 2023. Accessed May 5, 2023.
  • UpToDate. Inc. Clinical features and diagnosis of peripheral lymphedema. https://www.uptodate.com. Updated April 24, 2023. Accessed May 5, 2023.
  • UpToDate, Inc. Clinical staging and conservative management of peripheral lymphedema. https://www.uptodate.com. Updated April 2023. Accessed May 5, 2023.
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  • UpToDate, Inc. Management of late complications of head and neck cancer and its treatment. https://www.uptodate.com. Updated April 2023. Accessed May 5, 2023.
  • UpToDate, Inc. Overview of long-term complications of therapy in breast cancer survivors and patterns of relapse. https://www.uptodate.com. Updated April 2023. Accessed May 5, 2023.
  • UpToDate, Inc. Surgical treatment of primary and secondary lymphedema. https://www.uptodate.com. Updated April 2023. Accessed May 5, 2023.