Latest Review Date: November 2023

Category: Surgery

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)

In accordance with the mandate listed above, liposuction is covered when used to treat lymphedema resulting from a mastectomy and ordered by the individual’s treating physician.

POLICY:

For dates of service on 11/17/22 and after:

Liposuction for lymphedema is considered investigational.

If submitted for liposuction for the treatment of lipedema, refer to MP 106 Reconstructive versus Cosmetic Surgery.

For dates of service on 12/4/21 - 11/16/22:

Liposuction for lipedema or lymphedema is considered investigational.

For dates of service 11/15/19 – 12/3/21:

Liposuction (lipectomy) for the treatment of lipedema is considered investigational.

DESCRIPTION OF PROCEDURE OR SERVICE:

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.

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 abnormal accumulation of interstitial fluid and fibroadipose tissue in subcutaneous tissues or body cavities. In the extremities, capillaries in the superficial lymphatic system drain the lymph in the skin and subcutaneous tissue, which then flows into the deep system and then the lymph nodes, finally draining into the venous circulation. Accumulation of interstitial lymph fluid occurs when the accumulation of lymph exceeds the capacity of the system to drain. The excessive fluid may cause the accumulation and hypertrophy of fat cells.

Primary lymphedema may occur due to congenital anomalies or an inherited condition. Secondary lymphedema has a variety of causes that reduce lymph drainage including surgical removal of lymph nodes, post-radiation fibrosis, scarring of lymphatic channels, obesity, and chronic lymphatic overload. Cancer-associated lymphedema can occur due to obstruction, infiltration, removal of lymph nodes, irradiation, or medications. Nearly all cases of lymphedema in the U.S. are secondary to cancer or cancer treatment.

The most common cancer-associated lymphedema occurs in women who have undergone axillary surgery and/or axillary radiation therapy for breast cancer. The risk of developing arm lymphedema is associated with the extent of axillary lymph node dissection, and there is a greater risk of lymphedema in breast cancer patients who undergo dissection compared to those who undergo biopsy.

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

Adapted from Schavit et al (2018)

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.

KEY POINTS:

This evidence review was created in October 2021 with a search of the PubMed database. The most recent literature update was performed through August 23, 2023.

SUMMARY OF EVIDENCE:

For individuals with lipedema who receive liposuction, the evidence includes case series with over 100 patients. Relevant outcomes are symptoms, change in disease status, functional outcomes, and quality of life. Baseline to post-treatment comparisons provide low quality evidence that liposuction reduces limb circumference and may reduce pain and improve mobility in patients with advanced lipedema who have failed conservative therapy. The durability of the procedure is uncertain and no studies were identified that compared liposuction to continued decongestive therapy. 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 a few small controlled trials and an uncontrolled observational study with 5 year follow-up. Relevant outcomes are symptoms, change in disease status, functional outcomes, and quality of life. The available studies suggest that arm volume can be reduced by the procedure, but follow-up is limited and the trials have a number of other limitations that include lack of blinding, subjective outcome measures, lack of a physiotherapy control, and small sample size. The most rigorous evidence to date is a consecutive series of over 100 patients with detailed methodology. This series indicates that patients who have failed conservative therapy can have complete reversal of excess volume in the short term and that gains can persist through 5 years of follow-up when compression therapy is continued after surgery. However, no studies 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.

PRACTICE GUIDELINES AND POSITION STATEMENTS:

American Association of Plastic Surgeons

A 2021 consensus document sponsored by the American Association of Plastic Surgeons evaluated the evidence on surgical treatment of lymphedema. The conference recommended, based on grade 1C (very low quality) evidence, that there is a role for debulking procedures such as liposuction and for liposuction combined with physiologic procedures in reducing the nonfluid component in lymphedema.

International Society of Lymphology

In 2020, the International Society of Lymphology published a consensus document on the diagnosis and treatment of peripheral lymphedema. The consensus of the panel was that liposuction has been show to completely reduce non-pitting lymphedema due to excess fat deposition, but long-term management requires strict patient adherence to compression garments.

International Consensus Conference on Lipedema

A 2017 international consensus conference on lipedema identified studies from Germany that reported long-term benefits for up to 8 years following liposuction, concluding that lymph-sparing liposuction is the only effective treatment for lipedema.

National Institute for Health and Care Excellence

National Institute for Health and Care Excellence (NICE) issued clinical guidance addressing the use of liposuction for chronic lymphedema in 2022. The guidance reviewed the evidence and concluded that current evidence on the safety and efficacy of liposuction for chronic lymphedema is adequate to support the use of this procedure provided that standard arrangements are in place for clinical guidance, consent and audit. The evidence on safety shows that the potential risks include venous thromboembolism, fat embolism and fluid overload. Patient selection should only be done by a multidisciplinary team with expertise in managing lymphedema. This procedure should only be done in specialist centers by clinicians with training and expertise in liposuction for lymphedema following agreed perioperative protocols.

The NICE also issued guidance for liposuction in lipedema in 2022. They recommend liposuction for lipedema should be used only in the research setting because the safety data for liposuction in lipedema is inadequate but concerning.

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Liposuction, lipedema, lipectomy, lymphedema, lipoedema, lipolymphedema,WHCRA, Women's Health and Cancer Rights Act

APPROVED BY GOVERNING BODIES:

Liposuction is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration (FDA).

BENEFIT APPLICATION:

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

ITS: Home Policy provisions apply

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

CURRENT CODING: 

CPT codes:   

REFERENCES:

1. 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.
2. 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. May-Jun 2007; 31(3): 259-65.
3. Baumgartner A, Hueppe M, Meier-Vollrath I, et al. Improvements in patients with lipedema 4, 8 and 12 years after liposuction. Phlebology. Mar 2021; 36(2): 152-159.
4. Buck DW 2nd, Herbst KL. Lipedema: A Relatively Common Disease with Extremely Common Misconceptions. Plast Reconstr Surg Glob Open. 2016 Sep 28;4(9):e1043.
5. Canning C, Bartholomew JR. Lipedema. Vasc Med. 2018 Feb;23(1):88-90.
6. 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.
7. Chia CT, Neinstein RM, Theodorou SJ. Evidence-Based Medicine: Liposuction. Plast Reconstr Surg. Jan 2017;139(1): 267e-274e.
8. Dadras M, Mallinger PJ, Corterier CC, Theodosiadi S, Ghods M. Liposuction in the Treatment of Lipedema: A Longitudinal Study. Arch Plast Surg. 2017 Jul;44(4):324-331.
9. Executive Committee of the International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology. Lymphology. 2020; 53(1): 3-19.
10. 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.
11. Halk AB, Damstra RJ. First Dutch guidelines on lipedema using the international classification of functioning, disability and health. Phlebology. 2017 Apr;32(3):152-159.
12. Hayes, Inc. Hayes Evidence Analysis Research Brief. Liposuction for the treatment of lipedema. Feb 15, 2019.
13. Hoffner M, Ohlin K, Svensson B, et al. Liposuction Gives Complete Reduction of Arm Lymphedema following Breast Cancer Treatment-A 5-year Prospective Study in 105 Patients without Recurrence. Plast Reconstr Surg Glob Open. Aug 2018; 6(8): e1912.
14. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
15. Kruppa P, Georgiou I, Schmidt J, et al. A 10- Year Retrospective before and after Study of Lipedema Surgery: Patient-Reported Lipedema-Associated Symptom Improvement after Multistage Liposuction. Plast Reconstr Surg. Mar 01 2022; 149 (3): 529e-541e.
16. Munch D. Wasserstrahlassistierte Liposuction zur Therapie des Lipdems. Journal for sthetische Chirurgie. 2017,10:7178.
17. National Institute for Health and Care Excellence (NICE). Liposuction for lymphoedema. IPG588. 2017. https://www.nice.org.uk/guidance/ipg588/resources/liposuction-for-chronic-lymphoedema-pdf-1899872175376069. 
18. National Institute of Health (NIH). Lipedema. Available: https://rarediseases.info.nih.gov/diseases/10542/lipedema.
19. National Institute for Health and Care Excellence (NICE). Liposuction for chronic lipoedema. Interventional procedures guidance.IPG721. 2022. https://www.nice.org.uk/guidance/ipg723.
20. 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.
21. Reich-Schupke S, Schmeller W, Brauer WJ, Cornely ME, Faerber G, Ludwig M, et al. S1 guidelines: Lipedema. J Dtsch Dermatol Ges. 2017 Jul;15(7):758-767.
22. 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.
23. Sandhofer M, Hanke CW, Habbema L, Podda M, Rapprich S, Schmeller W, et al. Prevention of progression of lipedema with liposuction using tumescent local anesthesia: results of an international consensus conference. Dermatol Surg. 2019 Jul 23.
24. Schmeller W, Meier-Vollrath I. Tumescent liposuction: a new and successful therapy for lipedema. J Cutan Med Surg. 2006 Jan-Feb;10(1):7-10.
25. Schmeller W, Hueppe M, Meier-Vollrath I. Tumescent liposuction in lipoedema yields good long-term results. Br J Dermatol. Jan 2012; 166(1): 161-8.
26. Shavit E, Wollina U, Alavi A. Lipoedema is not lymphoedema: A review of current literature. Int Wound J. Dec 2018; 15(6): 921-928. https://www.ncbi.nlm.nih.gov/books/NBK545818/pdf/Bookshelf_NBK545818.pdf
27. van de Pas CB, Boonen RS, Stevens S, et al. Does tumescent liposuction damage the lymph vessels in lipoedema patients? Phlebology. 2020;35(4):231-236.
28. Warren Peled A, Kappos EA. Lipedema: diagnostic and management challenges. Int J Womens Health. 2016 Aug 11;8:389-95.
29. Witte T, Dadras M, Heck FC, et al. Water-jet-assisted liposuction for the treatment of lipedema: Standardized treatment protocol and results of 63 patients. J Plast Reconstr Aesthet Surg. Sep 2020; 73(9): 1637-1644.
30. Wollina U, Heinig B. Treatment of lipedema by low-volume micro-cannular liposuction in tumescent anesthesia: Results in 111 patients. Dermatol Ther. Mar 2019; 32(2): e12820.
31. Wollina U, Heinig B, Nowak A. Treatment of elderly patients with advanced lipedema: a combination of laser-assisted liposuction, medial thigh lift, and lower partial abdominoplasty. Clin Cosmet Investig Dermatol. 2014 Jan 23;7:35-42.

POLICY HISTORY:

New Medical Policy

Medical Policy Panel, October 2021

Medical Policy Group, October 2021 (6) New medical policy, on Draft through 12/4/21. All information regarding Lipedema transferred from MP 719 Surgical Treatments for Lymphedema.

Medical Policy Panel, October 2022

Medical Policy Group, October 2022 (6): Updates to Key Points, Practice Guidelines and References.

Medical Policy Group, November 2022 (6): Updates to Policy statement to include, coverage may be subject to legislative mandates: Federal Women's Health and Cancer Rights Act (WHCRA).Policy title and policy statement updated to reflect removal of lipedema indication. On draft 11/17/22-01/01/2023.

Medical Policy Group, December 2022 (6): Added Key Words: WHCRA, Women's Health and Cancer Rights Act

Medical Policy Panel, October 2023

Medical Policy Group, November 2023 (6): Updates to Key Points, Practice Guidelines, Benefit Application and References.

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.