Surgical Treatments for Breast Cancer-Related Lymphedema

This policy covers physiologic microsurgical treatments for breast cancer–related lymphedema—such as lymphaticovenular anastomosis and vascularized lymph node transfer—aimed at improving lymphatic circulation and reducing symptoms. Coverage is intended for patients with secondary (post–breast cancer treatment) arm lymphedema with functioning lymphatic channels (typically stages I–II and early III) but is subject to member benefit plans and state law, excludes reductive/ablative procedures (e.g., liposuction), and does not cover advanced/irreversible lymphedema or procedures considered experimental (including certain preventive microsurgeries).

"Medically necessary reconstructive services intended to restore the physical appearance of body structures damaged by trauma."

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