Latest Review Date: June 2024

Category: Surgery

POLICY:

For dates of service January 3, 2022 and after:

Liposuction for Treatment of Lipedema

I. Liposuction for treatment of lipedema of the lower extremities is considered medically necessary when ALL of the following criteria are met:

• Diagnosis of lipedema of the lower extremities as defined by ALL of the following:
  • Absence of pitting edema; AND
  • Thickened subcutaneous fat in the affected lower extremities bilaterally and symmetrically with minimal involvement of the feet; AND
  • Tenderness and nodularity of fat deposits in lipedema affected areas; AND
  • Disproportionate fat distribution in the lower extremities relative to the upper body; AND
  • History of easy bruising; AND
  • Negative Stemmer sign;

AND

• Diagnosis of lipedema has been confirmed by ALL of the following:
  • A comprehensive medical examination completed by a primary care physician; AND
  • Consultation with a certified lymphatic therapist (CLT); AND
  • Consultation with a vascular surgeon;

AND

• Significant physical functional impairment (e.g., difficulty ambulating or performing activities of daily living); AND
• Assessment by the referring primary care physician or a vascular surgeon confirms that lipedema is an independent cause of the functional impairment; AND
• Failure of at least 6 consecutive months of conservative treatment, including ALL of the following:
  • Leg elevation;
  • Physical therapy evaluation and compliance with a home exercise program;
  • Compression garments;
  • Manual lymph drainage, if appropriate;

AND

• The procedure is expected to restore or improve the functional impairment; AND
• The area to be treated with liposuction has not previously been treated with liposuction; AND
• The post-procedure plan of care is to continue wearing compression garments as instructed and to continue conservative treatment.

Cosmetic Uses

II. Liposuction is COSMETIC when performed to enhance or otherwise alter physical appearance without correcting or improving a physiological function, except when performed as part of a covered breast reconstruction procedure.

Investigational Uses

III. Liposuction is considered investigational when the above criteria are not met and for all other conditions, including but not limited to treatment of lymphedema and as the sole procedure for breast reduction, due to a lack of clinical evidence demonstrating an impact on improved health outcomes.

Documentation Submission:

Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorization, when prior authorization is required. In addition, the following documentation must also be submitted:

1. Clinic notes documenting the diagnosis and describing the functional impairment(s);
2. Photographs that document the condition (e.g. lipedema of the lower extremities);
3. Clinic notes documenting duration and outcomes of previous treatment for the condition;
4. Clinic notes by the required specialists;
5. Post-procedure plan of care

NOTE: Coverage may be subject to legislative mandates, including but not limited to the following, which apply prior to the policy statements:

• Federal Women’s Health and Cancer Rights Act (WHCRA)
• Minnesota Statute 62A.25 Reconstructive Surgery

Coverage

In accordance with the mandates listed above, liposuction is covered when performed as a breast reconstruction procedure following or in conjunction with mastectomy or breast-conserving surgery due to a diagnosis of breast cancer. This includes liposuction for treatment of physical complications of the mastectomy, including lymphedema.

DESCRIPTION OF PROCEDURE OR SERVICE:

Lipedema is a chronic and progressive disorder characterized by symmetrical swelling and adipose (fat) tissue buildup. The condition may be confused with non-lipedema obesity or lymphedema due to increased limb size. The exact cause remains unknown but may be associated with hormones and heredity. While there is no cure for lipedema, treatment is focused on helping to alleviate the symptoms. Conservative management of lipedema includes compression garments, physical therapy, nutritional therapy, and leg elevation. Liposuction may be indicated when the condition fails to respond to conservative treatment.

Liposuction is a minimally invasive surgical technique for removing adipose tissue in which a cannula is inserted subcutaneously into the operative area to allow for suction removal of soft tissue. It may be used to remove fatty deposits when conservative treatment has failed.

Liposuction techniques include water-jet assisted liposuction (WAL), which uses a stream of saline to dislodge fat cells with simultaneous removal, and tumescent liposuction, in which a solution is injected into the tissue to decrease pain and bleeding. Suction-assisted protein lipectomy (SAPL) is a specialized form of liposuction intended to remove more solid tissue at deeper levels than standard liposuction. Liposuction may also be referred to as lipectomy or lipedema reduction surgery.

Definitions

The Stemmer sign describes the inability to pinch the skin of the proximal phalanx of the second or third toe in patients with lymphedema. If the examiner is unable to grab the dorsal skin between his/her thumb and index finger, the Stemmer sign is positive for lymphedema. In patients with lipedema alone, the Stemmer sign will be negative.

BENEFIT APPLICATION

Coverage is subject to member’s specific benefits. Group-specific policy will supersede this policy when applicable.

ITS: Covered if covered by the Participating Home Plan

FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan.

CURRENT CODING:

POLICY HISTORY:

Policy effective January 3, 2022.

October 2022: Annual review completed. No change to policy intent.

May 2023: Annual review completed. No change to policy intent.

June 2024: Annual review completed. No change to policy intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.