Manual Lymphedema Drainage (MLD)
DESCRIPTION
Lymphedema is a disorder of the lymphatic system that results in the excess accumulation of protein-containing lymphatic fluid in the affected body part, usually the extremities. Manual lymphatic drainage therapy is performed by applying a gentle massage in the direction of normal lymphatic flow of the affected extremities / areas. This massage stimulates the flow of lymphatic fluid through the lymphatic system and back to the bloodstream.
There are two types of lymphedema: primary and secondary. Primary lymphedema results from improper lymphatic development that is not attributed to injury, trauma, illness or disease. Inability to propel lymphatic fluid results in accumulation of the fluid in the interstitial or lymphatic space. Secondary lymphedema is most commonly caused by cancer and its related treatments (e.g. surgery or radiation).
Manual lymphedema drainage (MLD) is accomplished with complex decongestive physiotherapy, which is a 2-phase noninvasive regimen. Phase I consists of manual lymphatic massage / drainage, immediately followed by multilayered short stretch compression bandaging, remedial exercises, and meticulous skin care. Phase 2, the maintenance phase, focuses on self-care by means of daytime elastic sleeve or stocking compression, nocturnal wrapping, and continued exercises.
POLICY
Manual lymphedema drainage for the treatment of lymphedema in the affected extremities / region is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Manual lymphedema drainage of the unaffected extremities / region is considered investigational.
Manual lymphedema drainage involving a lymphatic full body assessment (e.g., lymph drainage therapy) is considered investigational.
MEDICAL APPROPRIATENESS
Manual lymphedema drainage (MLD) of the affected extremities / region for the treatment of lymphedema is considered medically appropriate if ALL of the following criteria are met:
As a component of Phase I complex decongestive physiotherapy (i.e.,MLD, compression, education, exercise, and skin care)
Individual has primary or secondary lymphedema
ANY ONE of the following:
Excess of 2.5 cm in affected limb, as compared with normal limb, when limb size is determined by one fixed-point circumference measurement
Excess of 10 cm in affected limb, as compared with normal limb, when limb size is determined by the sum of several fixed-point circumference measurements
Excess of 200 ml fluid in affected limb, as compared with normal limb, when limb size is determined by water displacement
Significantly increased spread of contrast dye or radioactive tracer in the superficial lymph capillary network of the skin when fluorescence microlymphography or lymphoscintigraphy, respectively, is undertaken
Individual with exacerbations of disease
ABSENCE of ALL of the following:
Acute infection of the affected body part
Venous or arterial obstruction (e.g., deep venous thrombosis)
Confirmed or suspected local disease or active malignancy
Anticoagulant therapy (Note: Deep vein thrombosis must be ruled out prior to initiation of therapy.)
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Education, regarding manual lymphedema drainage, of both the affected individual and his or her significant other is essential beginning the first day of therapy.
Manual lymphatic drainage is generally administered once a day until adequate control is obtained. Two sessions a day, for a limited period, may be appropriate for individuals with severe lymphatic edema. The duration of treatment is dependent upon individual response. The most significant improvement is generally achieved within the first week of therapy.
Manual lymphatic drainage is not appropriate for ongoing maintenance of lymphedema. It may also be appropriate for exacerbations of disease. In order to extend therapy sessions there must be documentation verifying that advances are being made. A licensed medical provider who is appropriately trained and certified to perform lymphedema therapy should perform manual lymphatic drainage (e.g., MD, DO, RN, LPN, or PT).
Published scientific evidence in the form of well-designed studies in peer review journals regarding the utilization of manual lymphedema drainage to unaffected extremities / areas or a lymphatic full body assessment is lacking.
SOURCES
Agency for Healthcare Research & Quality. (2010, May). Technology assessment: Diagnosis and treatmentof secondary lymphedema. (Project ID- LYMT0908). Retrieved July 20, 2011 from http://www.cms.gov/determinationprocess/downloads/id66aTA.pdf.
International Society of Lymphology. (2009). The diagnosis and treatment of peripheral lymphedema, A consensus document. Lymphology, 42 (2009), 51-60.
Lacomba, M., Sanchez, M., Goni, A., Merino, D., Moral, O., Tellez, E., et al. (2010). Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: Randomized, single blinded, clinical trial. British Medical Journal, 2010 (340). (Level 2 Evidence – Independent)
Lerner, R. (1998). Complete decongestive physiotherapy and the Lerner Lymphedema Services Academy of Lymphatic Studies (the Lerner School). Cancer, 83 (12), 2861-2863.
McLaughlin, S., Wright, M., Morris, K., Sampson, M., Brockway, J., Hurley, K., et al. (2008).Pprevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: Patient perceptions and precautionary behaviors. Journal of Clinical Oncology, 26 (32), 5220-5226. (Level 3 Evidence - Independent)
National Cancer Institute. (2011, June). Lymphedema. Retrieved July 20, 2011 from http://www.cancer.gov/cancertopics/pdq/supportivecare/lymphedema/healthprofessional.
Thiadens, S. R. J. (2005). Lymphedema: An information booklet (8th ed.). San Francisco: National Lymphedema Network. Inc.
ORIGINAL EFFECTIVE DATE: 7/1/2000
MOST RECENT REVIEW DATE: 11/10/2011
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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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