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202303-160413

2023

CIGNA Healthcare of NY

PPO

Cardiac/ Circulatory Problems

Surgical Services

Experimental/Investigational

Overturned

Case Summary

Diagnosis: Lymphedema.
Treatment: Lymphangiotomy, free omental flap with microvascular anastomosis and 1 day hospital stay.

The insurer denied the Lymphangiotomy, free omental flap with microvascular anastomosis and 1 day hospital stay.

The health plan's determination is overturned.

The patient is a female with secondary bilateral lower extremity and vulvar lymphedema from Bartholin's gland squamous cell carcinoma treatment that included hemi-vulvovaginectomy and inguinal lymph node dissection. She suffers from chronic recurrent infection in this area that has required several hospitalizations for intravenous (IV) antibiotic treatment. She has also failed several conservative therapeutic modalities.

The proposed treatment of surgical vascularized lymph node transfer using a free omentum flap represents the most promising treatment for this patient, who otherwise would continue her life of severe disabilities and numerous recurrent medical complications.

Given the prevalent evidence in the emerging field of lymphedema surgical intervention, I overturn the health plan's adverse determination and to support the coverage of the proposed health service or treatment lymphangiotomy, free omental flap with microvascular anastomosis and 1 day hospital stay.

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