1019T — Lymphovenous bypass per xtr
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- No specific documentation checklist or pre-authorization documentation requirements are stated in this policy for surgical procedures; the policy directs users to reference the member-specific benefit plan and applicable federal/state mandates: "When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan."
- If applied to Medicare Advantage in absence of NCD/LCD, MAO determinations should use objective evidence-based rationale (per Medicare IOM): "In the absence of a Medicare National Coverage Determination (NCD), Local Coverage Determination (LCD), or other Medicare coverage guidance, CMS allows a Medicare Advantage Organization (MAO) to create its own coverage determinations, using objective evidence-based rationale relying on authoritative evidence (Medicare IOM Pub. No. 100-16, Ch. 4, §90.5)."
- General clinical documentation expectations implied by the policy: record of prior conservative management (e.g., CDT) attempts and responses, objective lymphedema measurements (volume/circumference/ICG/bioimpedance) and outcome data would be necessary for clinical decision-making and for any research/authorization review (policy emphasizes CDT as first-line and notes studies requiring objective measures), but the policy does not list these as formalrequired items.
Key Coverage Criteria
- None — surgical procedures for the prevention or treatment of Lymphedema are considered unproven and not medically necessary. (Policy statement: "Surgical procedures for the prevention or treatment of Lymphedema are unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.")
- First-line treatment is conservative management with complete decongestive therapy (CDT) — i.e., compressive garments, skin hygiene, limb compression, manual lymphatic drainage, and exercise (described in Background/Description of Services) (this is presented as standard of care; surgical approaches are considered only investigational/unproven according to this policy).
- Medically necessary reconstructive services intended to restore the physical appearance of body structures damaged by trauma.
- When an enrollee elects reconstruction after a mastectomy, coverage for surgery and reconstruction of the breast on which the mastectomy was performed is required.
- Coverage for surgery and reconstruction of the contralateral breast when performed to produce a symmetrical appearance is required.
- Coverage for prostheses related to mastectomy and reconstruction is required.
9 Active Policies
UHC-POL-surgical-treatment-lymphedema — Surgery for the Prevention and Treatment of Lymphedema
UMR-POL-UMR-surgical-treatment-lymphedema — Surgery for the Prevention and Treatment of Lymphedema
SUREST-POL-SUREST-surgical-treatment-lymphedema — Surgery for the Prevention and Treatment of Lymphedema
BCBSIL-SUR701.024 — Surgical Treatments for Breast Cancer-Related Lymphedema
Related Codes
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