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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyProvidence Lymphedema Surgery Coverage | OpenPayer
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    ModifiedProvidence Health PlanPolicy 341

    Surgical Treatments for Lymphedema

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    Medicare coverage decisions for surgical lymphedema treatment when Medicare statutes, regulations, NCDs, LCDs, or manuals do not fully establish coverage criteria.

    Policy Summary
    PayerProvidence Health Plan
    PolicySurgical Treatments for Lymphedema
    Policy CodePolicy 341
    Change TypeModified — procedure-code updates
    Effective DateOctober 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization for an unlisted code submitted for a potentially covered service addressed in this policy.
    SourceLink
    POLICY UPDATE CHANGES

    The policy underwent procedure-code updates.

    1Noridian LCDs identified
    4

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Policy cross-references
    2Surgical categories
    20+Listed procedure and HCPCS codes
    RecommendedUnlisted-code authorization

    Coverage Criteria

    When Medicare Coverage Criteria Are Not Fully Established

    Apply the following criteria when Medicare coverage criteria are not fully established:

    Internal Medicare Advantage coverage criteria: For surgical treatments for lymphedema without established criteria in Medicare statutes, regulations, a National Coverage Determination, a Local Coverage Determination, or a coverage manual, apply Company medical policy criteria for medical-necessity decision-making. Determinations are individualized and consider applicable coverage and benefit criteria, the member's medical history, diagnoses, functional status, comorbidities, physician recommendations, and clinical notes.

    Medicare coverage criteria are considered not fully established for many surgical lymphedema procedures.

    Suction-Assisted Lipectomy and Lipoma Removal

    Covered only when the following requirement is met:

    Suction-assisted lipectomy used to remove a lipoma may be considered reconstructive when the clinical record clearly demonstrates medical necessity for lipoma removal; all other uses are considered cosmetic and non-covered.

    The referenced Medicare Local Coverage Determination for Plastic Surgery states that most lipomas are benign and do not require removal.

    Under the referenced Medicare LCD for Plastic Surgery (L35163), suction-assisted lipectomy used to remove a lipoma may be considered reconstructive only when the clinical record clearly demonstrates medical necessity for removal. All other uses are considered cosmetic and non-covered.

    The Noridian Local Coverage Article for lymphedema decongestive treatment (A55710) addresses non-surgical lymphedema treatment and is not applicable to surgical treatments for lymphedema.

    For suction-assisted lipectomy used to remove a lipoma, the clinical record must clearly demonstrate medical necessity for the removal. The referenced LCD notes that most lipomas are benign and do not require removal; documentation should therefore support why removal is medically necessary.

    Procedure and HCPCS Coding

    CPTCPT
    1019TLymphovenous bypass, including robotic assistance, when performed, per extremity
    1081TMicrovascular anastomosis between a lymph node and a vein, including robot assistance, when performed; initial anastomosis
    1082TMicrovascular anastomosis between a lymph node and a vein, including robot assistance, when performed; each additional anastomosis (List separately in addition to code for primary procedure)
    14000Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
    14001Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
    14020Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less
    14021Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm
    14040Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
    14041Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
    14060Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
    1–10 of 30
    1/3
    HCPCSHCPCS
    49906Free omental flap with microvascular anastomosis
    Procedure and HCPCS codes listed in the policymixed
    14060Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
    14061Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm
    14301Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm
    14302Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)
    15832Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
    15833Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
    15834Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
    15835Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock
    15836Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
    15837Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm/hand
    1–10 of 22
    1/3

    Provider and Billing Actions

    Prior Authorization

    Apply Company criteria when Medicare criteria are incomplete

    When Medicare coverage criteria are not fully established for a surgical lymphedema treatment, apply Company medical policy criteria for medical-necessity decision-making. Determinations consider applicable coverage and benefit criteria, the member’s medical history, diagnoses, functional status, comorbidities, physician recommendations, and clinical notes.

    Prior Authorization

    Obtain prior authorization for potentially covered unlisted services

    For an unlisted code submitted for a potentially covered service addressed in this policy, obtain prior authorization to help avoid post-service denial. Unlisted codes are reviewed at the claim level for medical necessity, correct coding, and pricing.

    Documentation Required

    Lymphedema Surgery Background

    Lymphedema surgery may be excisional or reconstructive. Excisional procedures remove redundant tissue or the solid component of chronic, severe lymphedema and may include debulking, liposuction, circumferential suction-assisted lipectomy, and suction-assisted protein lipectomy. Reconstructive, or physiologic, procedures attempt to improve lymphatic drainage through lymphovenous anastomosis, artificial lymph channels, lymph node transfer, or tissue transfer. Microsurgical procedures target the fluid component that predominates in earlier disease stages.

    Procedure Definitions

    Excisional lymphedema surgery
    DefinitionSurgical procedures that resect redundant tissue associated with long-standing severe lymphedema and elephantiasis.
    ExamplesDebulking and liposuction-related procedures, including lipoplasty, suction-assisted lipectomy, circumferential suction-assisted lipectomy (CSAL), liposuction in lymphedema, and lympho-liposuction.
    Tissue addressedRedundant tissue that may develop in long-standing severe lymphedema and elephantiasis.
    Reconstructive (physiologic) lymphedema surgery
    DefinitionSurgical procedures intended to improve lymphatic drainage.
    Lymphatic reconstructionCreation of lymphovenous anastomoses or artificial lymph channels.
    Policy Summary
    PayerProvidence Health Plan
    PolicySurgical Treatments for Lymphedema
    Policy CodePolicy 341
    Change TypeModified — procedure-code updates
    Effective DateOctober 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization for an unlisted code submitted for a potentially covered service addressed in this policy.
    SourceLink
    On This Page
    Coverage CriteriaProcedure and HCPCS CodingProvider and Billing ActionsLymphedema Surgery BackgroundProcedure Definitions

    Document medical necessity for lipoma removal

    For suction-assisted lipectomy used to remove a lipoma, ensure the clinical record clearly demonstrates medical necessity for the lipoma removal. Most such tumors are benign and do not require removal.

    Denial Risk

    Support medical necessity for suction-assisted lipectomy

    Suction-assisted lipectomy used to remove a lipoma is considered reconstructive only when the clinical record clearly demonstrates medical necessity. All other uses are considered cosmetic and non-covered.

    Denial Risk

    Avoid denial of non-covered unlisted services

    An unlisted code submitted for a non-covered service addressed in this policy will be denied as not covered. Claims may also be affected by provider contracts, member benefits, eligibility, potential utilization audits, NCCI procedure-to-procedure edits, and CMS medically unlikely edits.

    ExamplesMicrosurgical treatment, lymph node transfer (LVT), vascularized lymph node transfer (VLNT), and tissue transfers.
    Suction-assisted protein lipectomy (SAPL)
    Full termSuction Assisted Protein Lipectomy (SAPL).
    Clinical purposeUsed to reduce the solid component of swelling in chronic lymphedema.
    Procedure categoryAn excisional lymphedema procedure involving suction-assisted removal of the solid component of swelling.
    Microsurgical treatment
    DefinitionMicrosurgical procedures used as reconstructive (physiologic) treatment to improve lymphatic drainage.
    Included procedureMicrosurgical lymphatico-venous anastomosis.
    Included proceduresLymphatic-capsular-venous anastomosis and lymphovenous bypass.
    Primary targetThe fluid component, which predominates at earlier stages of lymphedema.