Lipedema is a condition in which there is a pathological deposition of fatty tissue, usually below the waist, leading to progressive leg enlargement. There is no cure for lipedema and it does not respond well to diet and exercise.
Incidence: Estimates of the incidence of lipedema range as high as 11% of the post-pubertal female population, which is approximately 17 million women in the United States alone. Normal fat is 7%-23% for men and 20% to 35% in women w/ normal BMI. Lipedema is widely under and misdiagnosed as simply obesity or lymphedema.
Diagnosis: There are no diagnostic tests for lipedema; differential diagnosis is based on a physical exam and patient history.
Reconstructive Liposuction: Care should be taken to refer to LS-TL for lipedema as reconstructive and never cosmetic. Avoid using terms such as “contouring”, “improve appearance”, “aesthetic” or “cosmetic liposuction” in all Provider notes and pre-authorization letters. I recommend all plastic surgeons to remove those terms (in regard to lipedema) from their website and any blogs. The medical (CPT™) term for liposuction is lipectomy.
Reconstructive Surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance (AMA and ASPS definition). The Medicare National Policy for reconstructive surgery requires that the procedure be “reasonable and necessary…for treatment of illness or injury or to improve the functioning of a malformed body member.” [Reviewed MAR 2020].
There are numerous different types (techniques/modalities) of liposuction. Not all would be considered medically necessary or correct for lipedema. However, the AMA CPT™ codes make no distinction between liposuction modalities or techniques (lymph-sparing, tumescent liposuction; WAL™; PAL™, ultrasound; BodyJet™; CoolSculpting™, et. al.). There are four liposuction CPT™ codes; they are simply referred to as “suction assisted lipectomy”: 15876 (head and neck), 15877 (trunk), 15878 (upper extremity), and 15879 (lower extremity). I would recommend using the phrase, Lymph-Sparing, Tumescent Liposuction (LS-TL) because it differentiates itself from cosmetic liposuction; lymph-sparing refers to the specific technique used for removing lipedema fat; tumescent refers to the injection of water and lidocaine into the removal site.
Documentation: It is imperative that Providers use verbiage that explains/reinforces that liposuction for lipedema is uniquely a reconstructive surgery determined by medical necessity; all documentation should follow the reconstructive guidelines above. Documentation must demonstrate to the medical insurance company the patient has completed conservative non-surgical treatment of lipedema without adequate relief of their lipedema symptoms.
Positive Outcomes: Research shows lymph-sparing liposuction yields good long term results in reduction of lipedema pain and in stopping the progression of lipedema. (Cornely et al., 2006; Schmeller et al., 2006; Warren et al., 2007; Rapprich et al., 2011, 2012).
The need for conservative therapies such as Manual Lymphatic Drainage (MLD) and compression is greatly reduced in almost all patients, and in some cases, conservative therapies can be eliminated, after lymph sparing liposuction [Karen Herbst blog, 2014].
Dangers of non-treatment Due to the development of secondary lymphedema and the irreversible damage to the lymphatic system that occurs in later stages of the disease, liposuction should be implemented as part of the standard therapy for lipedema at early stages. This will prevent disease progression, improve quality of life, and reduce the need for decongestive therapy.
Carrier Liposuction Policy
Denials (often) do not
address lipedema as a diagnosis. Tumescent liposuction is the only effective
treatment for an incurable disease of unknown etiology to reduced patient pain,
improved their quality of life, reduction of psychological stress, overall
severity score improved (Rapprich 2010) and prevent progression of the disease
and expensive treatment.