The information below would be of most interest to those performing liposuction for lipedema, and in particular those who are interested in obtaining carrier reimbursement for the procedure. Please see my other posts concerning reconstructive versus cosmetic and medical necessity for coverage of those important reimbursement issues. The information below is just one viewpoint and the term described below is not currently widely recognized. Petitioning for a new CPT code and description will take years. It is a long-term process. This is presented to start the conversation. (May 12 2020).
All the evidence and guidelines support that not only is a modification of or derivation of suction lipectomy the most effective treatment to relieve symptoms of and ameliorate disability caused by lipedema-modified suction lipectomy is the only treatment of lipedema shown to halt its progression. It goes by many names:
- Tumescent Liposuction
- Lymph-Sparing Liposuction
- Lymph-Sparing, Tumescent Liposuction
- Water-Assisted Liposuction (WAL)
It can also be referred to as reconstructive/medically necessary liposuction for lipedema (to differentiate it from cosmetic liposuction). That is more of a description related to reimbursement rather than a description of the actual procedure. However, currently the four CPT (suction-assisted lipectomy) codes do not address any of these details.
The proper description of the liposuction for lipedema modification is Fibro-Lympho-Lipo-Aspiration (FLLA). The term is specifically referenced in the paper below:
18. Campisi CC, Ryan M, Boccardo F, Campisi C. Fibro-Lipo-Lymph-Aspiration With a Lymph Vessel Sparing Procedure to Treat Advanced Lymphedema After Multiple Lymphatic-Venous Anastomoses: The Complete Treatment Protocol. Ann Plast Surg. 2017;78(2):184-190. doi: 110.1097/SAP.0000000000000853.
Everything about the surgical suction application via cannula is different from standard suction lipectomy. The goal is to relieve symptoms, ameliorate disability, improve function and halt disease progression.
The technique is vastly different. Only small blunt cannulas are used, great care is used to not injure lymphatic which are already abnormal and increased risk of injury. Only the longitudinal orientation of cannulas is used at critical junctures. Preoperatively I scan and mark critical lymphatic structures. The surgery averages 4-5 hours, removed much larger aspirate volume than cosmetic suction lipectomy.
The benefit to lymphatics function comes not only from the removal of subcutaneous adipose tissue, but also the all components of the loose connective tissue including removing fibrosis in the interstitial space.
That is why Fibro-Lympho-Lipo-Aspiration (FLLA) is the best description of the procedure.
The term, suction lipectomy, suggests a technique whereby surgical insertion of cannulas into tissue attached to suction under tumescent anesthesia only removes subcutaneous fat for cosmetic improvements.
Fibro-Lympho-Lipo-Aspiration is directed at changing all components of the Loose Connective Tissue [ LCT]. For example, the application of suction-assisted cannulas has been shown to positively alter lymphatic function in patients with chronic lymphedema.13,15 Lymphatic stasis results in dermal fibrosis, deposition of proteoglycans and fibrosis in the matrix, and excess adipose tissue accumulation.16,17
Suction lipectomy for lymphedema, or more specifically, Fibro-Lymph-Lipo-Aspiration, has been shown to decrease limb volume in extremities with chronic lymphedema after the restoration of lymphatic flow with lymph node transplant or lympho-veno anastomosis through the removal of solid adipose and fibrotic material that is a result of lymphatic stasis.
FLLA on as a modification of suction lipectomy results in a sustained volume reduction of the limb, sustained improvement in lymphatic function and reduced risk of cellulitis in both lipedema and lymphedema.18
Again, the goal of this surgery is not removal of fat.
Fat may be an innocent bystander in the disease progression. The interstitial space, fibrosis and the subsequent development symptoms are the result of inflammation and increased extracellular fluid accumulation is what causes the symptoms and much of the disability.
Suction lipectomy and its CPT 15879 is a completely inadequate code. Its description is completely inadequate for the procedure. Those carriers that reimburse for the procedure have valued the code at $1,412. There is no RBRVS valuation (no Medicare fee schedule) because it is considered a cosmetic code.
The skill, work involved and time assigned to this code by payers is not adequate. It best describes a cosmetic procedure in person close to ideal body weight, who has a “small pocket” of cosmetically unappealing fat removed to improve their shape.
When payers value lipectomy codes they assume at most a liter or slightly more of fat removed in an hour or less.
Prior to surgery, surgeons assess lymphatic landmarks, including peri-saphenous lymphatic collection pathways to plan to execute the surgery without their disruption. A great deal of skill is required to not injure lymphatics. The surgery takes at least 4 hours and will often remove over 12 + Liters or 25 lbs of aspirate. This is not just fat removed, but also proteoglycans and other extracellular matrix components.
Data supports the improvements in lymphatic function and symptoms that result from my surgery. All the data from the phlebologist / venous and lymphatic specialist in Germany like Rapprich and Schmeller show improvements in QOL and lymphatic function surrogates like the need for compression and compression pump use. So again, it is much more that fat removal.
The free market valuation of lipedema surgery is from 7-30K for the procedure.
Typical surgeon’s fees range from 7K (discounted) to 16K. The work involved in getting approval and payment from third-party payors for the surgery makes 16 K the number difficult to discount with 3rd party payers. Negotiating for single-payer agreements or contracted rates 10-12K makes sense.
REFERENCES
2. Schaverien MV, Munnoch DA, Brorson H. Liposuction Treatment of Lymphedema. Semin Plast Surg. 2018;32(1):42-47. doi: 10.1055/s-0038-1635116. Epub 1632018 Apr 1635119.
3. Peprah K, MacDougall D. 2019.
15. Brorson H. Liposuction in arm lymphedema treatment. Scand J Surg. 2003;92(4):287-295.
16. Zampell JC, Aschen S, Weitman ES, et al. Regulation of adipogenesis by lymphatic fluid stasis: part I. Adipogenesis, fibrosis, and inflammation. Plast Reconstr Surg. 2012;129(4):825-834. doi: 810.1097/PRS.1090b1013e3182450b3182452d.
17. Schneider M, Conway EM, Carmeliet P. Lymph makes you fat. Nat Genet. 2005;37(10):1023-1024.
18. Campisi CC, Ryan M, Boccardo F, Campisi C. Fibro-Lipo-Lymph-Aspiration With a Lymph Vessel Sparing Procedure to Treat Advanced Lymphedema After Multiple Lymphatic-Venous Anastomoses: The Complete Treatment Protocol. Ann Plast Surg. 2017;78(2):184-190. doi: 110.1097/SAP.0000000000000853.