38589
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
- For lipedema surgical coverage: documentation that ALL listed lipedema criteria are met, including: pain, easy bruising, nodularity of fat deposits, tenderness, physical function impairment, absence of pitting edema (unless coexisting lymphedema), negative Stemmer sign (unless coexisting lymphedema), lack of improvement after weight loss if applicable, lack of improvement with limb elevation, lack of response to at least three consecutive months of medical management, and photographs that confirm bilateral symmetric adiposity in the affected extremities.
- For lymphedema excisional/liposuction coverage: documentation of physical function impairment, documentation of failure/lack of response to at least three consecutive months of medical management (e.g., compression garments, manual lymphatic drainage), and documentation that patient will continue postoperative compression garment use as instructed.
- For microsurgical procedures/VLNT coverage: documentation of ONE qualifying sign/symptom (physical function impairment OR history of chronic/recurrent skin conditions OR significant pain/weakness), ONE quantitative measurement (volumetry differential by circumferential measurements and/or perometry differential meeting >10% if affected is dominant or >7% if non-dominant OR lymphoscintigraphy demonstrating delayed transit time to first-level lymph nodes or a dermal backflow pattern), documentation of lack of response to at least three consecutive months of medical management, and documentation of postoperative compression garment plan/commitment.
Key Coverage Criteria
- Lipedema: Liposuction, (i.e., water jet-assisted liposuction, micro-cannular) or lipectomy for the treatment of lipedema of the extremities, including the hips and buttocks, is considered medically necessary when ALL of the following criteria are met:
- - pain in the affected areas
- - easy bruising
- - nodularity of fat deposits in lipedema affected areas (dimpled or orange peel texture)
- - tenderness
- - physical function impairment (e.g., difficulty ambulating, performing activities of daily living)
6 Active Policies
CIGNA-0531 — Lymphedema and Lipedema Surgical Treatments - (0531)
BCBSIL-SUR701.024 — Surgical Treatments for Breast Cancer-Related Lymphedema
BCBSMT-SUR701.024 — Surgical Treatments for Breast Cancer-Related Lymphedema
BCBSNM-SUR701.024 — Surgical Treatments for Breast Cancer-Related Lymphedema
BCBSOK-SUR701.024 — Surgical Treatments for Breast Cancer-Related Lymphedema
Related Codes
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