ModifiedRegencePolicy M-SUR220

Surgical Treatments for Lymphedema and Lipedema

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This Medicare Advantage policy governs coverage evaluation for surgical treatments of lymphedema and lipedema, including reductive and lymphatic surgical procedures. It does not address nonsurgical treatments such as compression therapy, manual lymphatic drainage, complete decongestive therapy, or pneumatic compression pumps.

Policy Summary

PayerRegence

PolicySurgical Treatments for Lymphedema and Lipedema

Policy CodePolicy M-SUR220

Change TypeRevisedno material clinical or coverage changes

Effective DateJanuary 1, 2027

Last ReviewSep 1, 2026

Next Review DateJune 1, 2027

Key ActionCheck the Medicare Pre-authorization List to determine whether prior authorization is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7Surgical treatment types without Medicare coverage guidance

7CPT codes listed

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ModifiedRegencePolicy M-SUR220

Surgical Treatments for Lymphedema and Lipedema

Customize your policy alerts

Sign up for regence Policy M-SUR220 alerts

Get alerted when Policy M-SUR220 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerRegence

PolicySurgical Treatments for Lymphedema and Lipedema

Policy CodePolicy M-SUR220

Change TypeRevisedno material clinical or coverage changes

Effective DateJanuary 1, 2027

Last ReviewSep 1, 2026

Next Review DateJune 1, 2027

Key ActionCheck the Medicare Pre-authorization List to determine whether prior authorization is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7Surgical treatment types without Medicare coverage guidance

7CPT codes listed

Coverage Criteria

Investigational or Experimental Procedures

A service is noncovered when the following condition is met:

Investigational or experimental service: The procedure or device lacks scientific evidence regarding safety and efficacy because it is investigational or experimental.

The service is noncovered as not reasonable and necessary to treat illness or injury.

Medicare Noncoverage Limitations

Coverage is subject to Medicare and member benefit requirements. A service is noncovered when any of the following applies:

ONE of

The service is cosmetic; investigational or experimental; or not medically reasonable and necessary under Title XVIII of the Social Security Act, section 1862(a)(1)(A).
FDA approval or assignment of a CPT or HCPCS code alone does not establish medical necessity or Medicare coverage.

This policy addresses only surgical treatments for lymphedema and lipedema. Nonsurgical treatments—including compression or bandage therapy, manual lymphatic drainage, complete decongestive therapy, and pneumatic compression pumps—are outside the scope of this policy.

Coverage remains subject to the member’s Evidence of Coverage and applicable Medicare requirements. Medicare and member benefit documents exclude services or procedures considered investigational, experimental, cosmetic, or not medically reasonable and necessary under Title XVIII of the Social Security Act, section 1862(a)(1)(A).

A procedure or device that lacks scientific evidence regarding safety and efficacy because it is investigational or experimental is considered not reasonable and necessary to treat illness or injury and is therefore noncovered.

The assignment of a CPT or HCPCS code, or FDA approval for a specific indication, does not by itself establish that a procedure is medically reasonable and necessary or covered by Medicare. Medical necessity and coverage are evaluated separately for the Medicare population.

Coding Information

CPT CodesCPT

1019T	Lymphovenous bypass, including robotic assistance, when performed, per extremity
1081T	Microvascular anastomosis between a lymph node and a vein, including robot assistance, when performed; initial anastomosis
1082T	Microvascular 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)
15832	Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
15833	Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
15834	Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
15835	Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock
15836	Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
15837	Excision, excessive skin and subcutaneous tissue (includes lipectomy)
15838	Excision, excessive skin and subcutaneous tissue (includes lipectomy)

1–10 of 15

1/2

HCPCS CodesHCPCS

38999

Unlisted procedure, hemic or lymphatic system

Provider and Billing Actions

Prior Authorization

Check the Medicare Pre-authorization List

Check the Medicare Pre-authorization List web page before rendering treatment. Codes not listed on the pre-authorization website do not require prior approval, but may not be considered medically necessary for any indication.

Codes requiring prior authorization include 1019T, 1081T, 1082T, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, and 38999.

Documentation Required

Document Medicare medical necessity

Follow Medicare medical-necessity requirements when rendering treatment to beneficiaries, including for codes related to lymphedema or lipedema that are not included in this policy. A CPT or HCPCS code or FDA approval alone does not establish that a procedure is medically reasonable and necessary or covered by Medicare.

Clinical Background

Lymphedema is an accumulation of fluid caused by disrupted lymphatic drainage. It may be primary, resulting from congenital or inherited abnormalities of the lymphatic system, or secondary, resulting from acquired lymphatic damage, such as after breast cancer treatment. Lipedema is a distinct condition involving increased subcutaneous fat and non-pitting swelling, typically affecting the lower extremities but sometimes the upper extremities.

Proposed surgical treatments include reductive procedures such as suction-assisted protein lipectomy and microsurgical lymphatic procedures, including lymphatic venous anastomosis and vascularized lymph node transfer.

Definitions

Lymphedema

DefinitionAccumulation of fluid due to disruption of lymphatic drainage.

Primary lymphedema

DefinitionLymphedema caused by congenital or inherited abnormalities in the lymphatic system.

Secondary lymphedema

DefinitionLymphedema caused by acquired damage to the lymphatic system.

Lipedema

Definition