Complex Decongestive Physiotherapy:

Aetna considers a course of complex decongestive physiotherapy (CDP), also called manual lymphoid drainage, medically necessary when both of the following criteria are met:

1. The member has any of the following conditions:

   1. Intractable lymphedema of the extremities, unrelieved by elevation; or
   2. One or more previous admissions to treat complications of intractable lymphedema (i.e., cellulitis, ulceration); or

   3. Evidence of ulceration due to lymphedema; and

2. The member has shown a past record of compliance and the member or his/her caregiver is capable of following the instructions associated with CDP.

Lymphedema Pumps:

Aetna considers lymphedema pumps (pneumatic compression devices) medically necessary durable medical equipment (DME) for home use for the treatment of lymphedema if the member has undergone a four-week trial of conservative therapy and the treating doctor determines that there has been no significant improvement or if significant symptoms remain after the trial. The trial of conservative therapy must include use of an appropriate compression bandage system or compression garment, exercise, and elevation of the limb. The garment may be prefabricated or custom-fabricated but must provide adequate graduated compression.

Note: For members without DME benefits, lymphedema pumps are only covered for members with arm lymphedema due to mastectomy for breast cancer who meet the criteria for a lymphedema pump stated above.*

When medical necessity criteria for a pneumatic compression device are met, a non-segmented device or segmented device without manual control of the pressure in each chamber is generally considered medically necessary to meet the clinical needs of the member.  A segmented device with manual control of the pressure in each chamber is considered medically necessary only if there is clear documentation of medical necessity in the individual case.  A segmented device with manual control of the pressure in each chamber is considered medically necessary only when there is documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression treatment using a non-segmented device with a segmented appliance/sleeve or a segmented device without manual control of the pressure in each chamber.

A 2-phase lymph preparation and drainage therapy device (Flexitouch Device, Tactile Systems Technology, Minneapolis, MN) is considered equally effective to standard segmented pneumatic compression devices.  

For Aetna’s clinical policy on pneumatic compression devices for chronic venous insufficiency, see CPB 500 - Intermittent Pneumatic Compression Devices for the Legs.

Note: Although the literature suggests that the use of lymphedema pumps is commonly initiated in the hospital, there is no medical necessity for this practice unless the member has other complications of lymphedema (i.e., cellulitis) that would require hospitalization. The use of lymphedema pumps can be initiated in the clinic or in the home setting.

Static Compression Sleeves:

Aetna considers static compression sleeves (e.g., the ReidSleeve, ArmAssist) to be medically necessary supplies for members with intractable lymphedema of the arms. Note: For members whose plans exclude coverage of supplies, static compression sleeves are only covered for intractable lymphedema of the arms due to mastectomy for breast cancer.*  See also CPB 482 - Compression Garments for the Legs.

Static Compression Garments for the Trunk:

Aetna considers static compression garments for the trunk experimental and investigational. There is a lack of peer-reviewed published literature evaluating the clinical utility of static compression garments for truncal lymphedema

Microsurgical Lymphaticovenous Anastomosis:

Aetna considers microsurgical lymphaticovenous anastomosis experimental and investigational for the treatment of members with chronic obstructive lymphedema because the long-term effectiveness of this procedure has not been established by the peer-reviewed medical literature.

*Note: HR 4328 (Public Law 105-277) requires individual and employer group health plans (including indemnity, PPO, POS and HMOs), that provide medical and surgical benefits with respect to a mastectomy, to provide coverage for lymphedema treatment in a manner determined in consultation with the attending physician and the member for a participant or beneficiary who is receiving benefits for a mastectomy and who elects breast reconstruction after the mastectomy. Therapy is subject to annual deductibles and co-insurance provisions for physical therapy. Therapy is not subject to visit limitation provisions for physical therapy.

Lymphedema refers to edema (i.e. swelling) due to inadequate lymphatic circulation related to either: (i) defective development of the lymphatics (primary lymphedema); or  (ii) destruction or obliteration of the lymphatic system (secondary lymphedema) due to either trauma, wounds, surgery, radiation therapy, or infection with a tropical filarial parasite.  Primary lymphedema typically involves the lower extremities and typically afflicts females.  When it arises at birth it is called lymphedema congenita, before the age of 35 it is called lymphedema praecox, and when arising later in life it is called lymphedema tarda.  Secondary lymphedema occurs most commonly after lymph node dissections.  For example, 10 to 20% of women with breast cancer who have undergone axillary dissection will experience lymphedema.  Leg edema can result after groin dissection, most typically for melanoma.  Lymphedema results in a feeling of heaviness, aching or tightness.  In severe cases, mobility can be impaired.  Development of angiosarcoma, know as the Stewart-Trewes syndrome, is a very rare complication of  long standing severe lymphedema.

The severity of lymphedema can be graded as follows:

Grade I: Mild and intermittent lymphedema which pits easily

Grade II: Moderate and persistent lymphedema, no pitting, unrelieved by elevation

Grade III: Fibrosclerotic lymphedema (elephantiasis)

Conservative treatment of lymphedema focuses on a combination of physical therapies: elevation of the arm or leg, manual physical therapy, wearing of various types of compression stockings/bandages, or pneumatic pumps.  

The use of elastic stockings is considered a valuable component of lymphedema therapy, and appears to be critical to the long term success of treatment.  Compliance with elastic stocking may be problematic since they are frequently hot, uncomfortable, and considered unsightly by some.  Lack of compliance may result in requests for further treatment, such as pneumatic pumps or complex decongestive physiotherapy.  However, elastic garments are a component of all treatments of lymphedema and compliance has a major impact on the success of any treatment of lymphedema.

Pneumatic pumps can consist either of static unicompartmental pumps where an equal amount of pressure is applied throughout the edematous limb, or a sequential pump which essentially attempts to “wring out” the edema by graded compression from distal to proximal.  Due to the short cycles of pressure, higher pressures can be applied compared to the static pumps.  Pressures higher than the systolic blood pressure are avoided; pressures up to 80 to 90 mm Hg are typical.  At this point sequential pumps (such as the Lymphapress or the Wright linear sequential pump) appear to be more commonly used than static pumps. The Lymphapress device is composed of a series of overlapping cells that apply a sequential pattern of compression moving distally to proximally along the affected limb.  Using this strategy, higher levels of pressure can be applied compared to other unicompartmental devices which apply the same degree of pressure along the entire limb. The Lymphapress device seems to be effective in acutely decreasing lymphedema, and many patients have purchased this device for home use.

The Flexitouch Device (Tactile Systems Technology, Minneapolis, MN) is a 2-phase lymph preparation and drainage therapy device. The device consists of an electronic controller unit and garments which are worn on the trunk and upper and lower affected extremities and connected to the controller unit by tubing harnesses. The garment consists of 32 inflatable chambers that sequentially inflate and deflate at 1 to 3 second intervals, according to one of the 13 pre-programmed treatment patterns selected.  Chamber pressure and treatment times can be adjusted.  The manufacturer states that device’s sequential action evacuates lymph from the trunk and extremities and drains it into the venous system.  The garments are made from stretch material and are fitted with Velcro enclosures, so custom fitting of garments is not required.  There are no published studies comparing the effectiveness of this 2-phase lymph preparation and drainage therapy device to standard segmented pneumatic compression devices.

Drug therapy with benzopyrone can also result in slow reduction of lymphedema. This drug is a protoeolytic agent which acts by activating macrophages, which then break down the protein-rich lymphedema fluid, thus decreasing its viscosity and thereby facilitating its flow.

A technique developed in Germany, complex decongestive physiotherapy (CDP), has been introduced in the United States.  CDP is most frequently offered in specialized clinics. Patients attend the clinics for about 4 hours a day for one to 4 weeks.  CDP consists of four basic components as follows:

1. Meticulous skin and nail care. The protein rich lymphedema fluid is highly susceptible to infection which can then further damage the lymphatics resulting in a vicious cycle.  Thus meticulous skin and nail care is required.  Emollients are often used to prevent drying and cracking of the skin and all fungal infections must be treated promptly.
2. Manual lymphatic drainage (MLD). This massage technique seems to be the unique component of this multidisciplinary approach and is based on the concept that the lymphatic system is subdivided into individual lymphotomes which communicate through collateral channels.  The idea behind MLD is to increase the collateral circulation between these lymphotomes, such that the lymphedema fluid can be shunted from an inadequately draining lymphotome into a normal one.  Thus, unlike other massage techniques, MLD begins with massage of the contralateral truncal lymphotome and then progresses toward the edematous extremity.  Theoretically, in this way the collateral circulation is opened and dilated and the lymphatic drainage is “decongested.”  There is no specific description of the technique of MLD, or theories as to how this technique can open and dilate collateral channels.Patients enrolled in the CDP clinic may undergo 1-2 such MLD sessions (about 45 minutes each) each day.
3. Bandaging. After the MLD session, the lymphedematous limb is wrapped with a pure cotton, minimally elastic bandages in order to provide adequate tissue pressure which in turn prevents reaccumulation of lymphedema.
4. Remedial Exercises. These exercises are performed while wearing the bandages, and thus the muscles contract against a firm external force, further stimulating lymph flow.

During the clinical sessions the patients receive additional counseling in various aspects of self management, such as skin care, nutrition, weight control, etc.  Prior to discharge from the clinic, the patient is fitted with an elastic support garment.  It is recommended that this garment be worn as much as possible, and even at night.  Some clinics may recommend wearing the bandages at night, and the compressive garment during the day.  The use of these garments can be gradually reduced as the patient improves, however, typically, the patient will need to continue wearing the compressive garment at least part time. An initial course of CDP may require 30 days, or in the case of lower extremity care, 45 days.

No conservative treatment is entirely curative and all require a committed physical therapy team and a committed and compliant patient.

Surgery has been used in patients with severe lymphedema.  Excisional surgical procedures involve resection of the redundant tissue that may develop in long-standing severe lymphedema and elephantiasis.

Physiologic surgical procedures attempt to provide or enhance lymphatic drainage with either anastomoses between lymphatic systems (i.e. linking subcutaneous tissues with the deep lymphatics), creating lymphovenous anastomoses or creation of artificial lymph channels.  These surgical techniques are controversial and rarely used.