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Date Printed: December 17, 2017: 04:32 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-91000-09

Original Effective Date: 06/15/10

Reviewed: 07/27/17

Revised: 08/15/17

Subject: Bioimpedance Devices for Detection and Management of Lymphedema

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Bioimpedance with the use of bioimpedance spectroscopy analysis, which uses resistance to electrical current to compare the composition of fluid compartments, has been evaluated as a technique for measuring lymphedema, a chronic accumulation of fluid and fibrous tissue that results from the disruption of lymphatic drainage. Bioimpedance spectroscopy is based on the theory that the level of opposition to flow of electric current (impedance) through the body is inversely proportional to the volume of fluid in the tissue. In lymphedema, with the accumulation of excess interstitial fluid, tissue impedance decreases.

Secondary lymphedema of the upper extremity may develop following surgical treatment for breast cancer; it has been reported in approximately 25% to 50% of women following mastectomy. This can be a chronic, disfiguring condition. It results from lymphatic dysfunction or disruption and can be difficult to accurately diagnose and manage. One challenge is identifying the clinically significant limb swelling through simple noninvasive methods. Many techniques have been used for documenting lymphedema including measuring differences in limb volume (volume displacement) and limb circumference.

The detection of subclinical lymphedema (i.e., the early detection of lymphedema before clinical symptoms become apparent) is another area of study. Detection of subclinical lymphedema (referred to as Stage 0 lymphedema) is problematic. Subclinical disease may exist for months or years before overt edema is noted. This approach generally involves comparison of preoperative with postoperative measurements, since existing differences between upper extremities (like the effects of a dominant extremity) may obscure early, subtle differences resulting from the initial accumulation of fluid. Bioimpedance has been proposed as one diagnostic test for this condition.

POSITION STATEMENT:

Devices using bioimpedance (bioelectrical impedance spectroscopy) for use in the diagnosis, surveillance, or treatment of members with lymphedema, including use in subclinical secondary lymphedema, is considered experimental or investigational. The evidence is insufficient to determine the effects of the technology on health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

93702

Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) (investigational)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services (L33777) located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Pneumatic Compression Devices, 09-E0000-31

OTHER:

None applicable

REFERENCES:

  1. Agency for Healthcare Research and Quality (AHRQ) Technology Assessment. Diagnosis and Treatment of Secondary Lymphedema (05/28/10).
  2. Ahmed RL et al. Lymphedema and Quality of Life in Breast Cancer Survivors: The Iowa Women’s Health Study. J Clin Oncol 26:5689-5696 (12/10/08).
  3. American Cancer Society. Lymphedema: What Every Woman with Breast Cancer Should Know (last revised 03/05/09).
  4. Blue Cross Blue Shield Association Medical Policy Reference Manual 2.01.82 Bioimpedance Devices for Detection and Management of Lymphedema, 06/17.
  5. ClinicalTrials.gov, Evaluation of the Validity of BIS as a Tool for Quantification of Lymphedema Through Comparison With Perometry and Self-Report; sponsored by Massachusetts General Hospital, accessed 06/27/17.
  6. ClinicalTrials.gov, A Limited Access Phase II Trial Utilizing Bioimpedance to Measure Lower Extremity Lymphedema Associated With the Surgical Management of a Vulvar Cancer; sponsored by Gynecologic Oncology Group, accessed 06/27/17.
  7. Czerniec SA, Ward LC, et al. Assessment of Breast Cancer-Related Arm Lymphedema – Comparison of Physical Measurement Methods and Self-Report. Cancer Investigations, 28:54-62, 2010.
  8. First Coast Service Options, Inc. (FCSO), Local Coverage Determination (LCD): Noncovered Services (L33777), accessed at fcso.com.
  9. Hayes SC et al. Lymphedema after Breast Cancer: Incidence, Risk Factors, and Effect on Upper Body Function. J Clin Oncol 26:3536-3542 (07/20/08).
  10. Kim L, Jeon JY, Sung IY, Jeong SY, Do JW, Kim HJ. Prediction of Treatment Outcome with Bioimpedance Measurements in Breast Cancer Related Lymphedema Patients. Ann Rehabil Med 2011; 35: 687-693.
  11. Laidley A, Anglin B. The impact of L-Dex((R)) Measurements in assessing breast cancer-related lymphedema as part of routine clinical practice. Front Oncol. 2016;6:192.
  12. McLaughlin, SA et al. Prevalence of Lymphedema in Women with Breast Cancer 5 Years after Sentinel Lymph Node Biopsy or Axillary Dissection: Objective Measurements. J Clin Oncol 26:5213 – 5219 (11/10/08).
  13. Moseley et al. Reliability of Bioimpedance Spectroscopy and Tonometry after Breast Conserving Cancer Treatment. Lymphat Res Biol. 2008; 6(2):85-7.
  14. National Cancer Institute. Lymphedema (PDQ®) Health Professional Version (last modified 06/13/11).
  15. National Lymphedema Network Position Statement- The Diagnosis and Treatment of Lymphedema, February 2011; accessed at lymphnet.org 06/27/17.
  16. Rockson et al. Bioimpedance analysis in the assessment of lymphoedema diagnosis and management. J Lymphoedema 2007, VOL 2; NUMB 1, pages 44 – 49.
  17. Shih YT et al. Incidence, Treatment Costs, and Complications of Lymphedema After Breast Cancer Among Women of Working Age: A 2-Year Follow-up Study. J Clin Oncol 27 (03/16/09).
  18. Stout NL, Gergich NL et al. Peroperative Assessment Enables the Early Diagnosis and Successful Treatment of Lymphedema. Cancer 2008; 112:2809-19. Published online 04/21/08 in Wiley InterScience.
  19. Ward et al. Operational equivalence of bioimpedance indices and perometry for the assessment of unilateral arm lymphedema. Lymphat Res Biol. 2009; 7(2):81-5.
  20. Ward et al. Quantitative bioimpedance spectroscopy for the assessment of lymphoedema. Breast Cancer Res Treat. 2009 Oct; 117(3):541-7. Epub 2008 Dec 11.
  21. York et al. Single frequency versus bioimpedance spectroscopy for the assessment of lymphedema. Breast Cancer Res Treat. 2009 Sep; 117(1):177-82. Epub 2008 Jun 18.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/27/17.

GUIDELINE UPDATE INFORMATION:

06/15/10

New Medical Coverage Guideline.

01/01/11

Annual HCPCS coding update. Added code 0239T.

01/01/12

Annual HCPCS coding update: notation regarding description of 38792 is revised.

07/15/12

Scheduled review; position statement unchanged, references updated.

06/15/13

Scheduled review; position statement unchanged, Program Exceptions section updated, references updated.

06/15/14

Scheduled review; policy title revised; position statement reformatted; references updated.

01/01/15

Annual coding update: removed 0239T; added 93702.

08/15/17

Review; Investigational position maintained; description section and references updated.

Date Printed: December 17, 2017: 04:32 PM