Commercial

Medical Policy

Title:

Bioimpedance for the Detection of Lymphedema

Policy #:

07.06.03c

Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

Bioimpedance spectroscopy is considered medically necessary and, therefore, covered when used to confirm a diagnosis of lymphedema in the following situation:

The individual is asymptomatic with history of surgery, radiotherapy, or trauma impacting the lymphatic system, and testing would guide decisions regarding early intervention (e.g., physical therapy, complete decongestive therapy).

Bioimpedance spectroscopy is considered medically necessary and, therefore, covered when used for surveillance of lymphedema in the following situations:

The individual is asymptomatic with history of surgery, radiotherapy, or trauma impacting the lymphatic system, and testing would guide decisions regarding early intervention (e.g., physical therapy, complete decongestive therapy); OR
The individual remains symptomatic following a course of conservative therapy for lymphedema, and testing would guide decisions regarding escalation of therapy (e.g., liposuction, surgery).

All other uses of bioimpedance spectroscopy are considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, bioimpedance spectroscopy is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA)

There are numerous devices approved by the FDA for bioimpedance for the detection of lymphedema.

Description

Lymphedema is a condition characterized by excess edema and protein in the tissues caused by fluid that is not drained by the lymphatic system. The lymphatic system is part of the body's circulatory system, and its main function is to drain fluid, absorb fats, maintain the body's fluid balance, and help defend the body against disease. The failure of this system can lead to lymphedema and other conditions.

There are two types of lymphedema: primary and secondary. Primary lymphedema is an inherited condition and is determined by genetic factors. Secondary lymphedema is usually caused by trauma, radiation therapy, surgery, or infection that causes a disruption in the lymphatic channels or loss of lymph nodes. One of the most common causes of secondary lymphedema is breast cancer treatment (surgical removal of lymph nodes and radiotherapy).

In time, lymphedema can lead to recurring infections, pain, and decreased or loss of function and mobility. Control of the condition usually involves elevation, exercise, compression bandaging, and massage. The practice of measuring limb girth with tape measures or the immersion of the limb in water to measure the displacement of the water is considered the gold standard for detection of lymphedema. One of the many problems associated with lymphedema involves early detection; however, detection in the early subclinical phase is difficult. While there is no cure for lymphedema, early detection and treatment are critical in achieving the optimal outcome for the individual.

A diagnosis of secondary lymphedema is based on history (e.g., cancer treatment, trauma) and physical examination (localized, progressive edema and asymmetric limb measurements) when other causes of edema can be excluded. Imaging, such as MRI, computed tomography, ultrasound, or lymphoscintigraphy, may be used to differentiate lymphedema from other causes of edema in diagnostically challenging cases.

In 2023, the International Society of Lymphology published the following guidance for staging lymphedema based on "softness" or "firmness" of the limb and the changes with an elevation of the limb:

Stage 0 (latent or subclinical): Swelling is not yet evident despite impaired lymph transport, subtle alterations in tissue fluid/composition, and changes in subjective symptoms. It can be transitory and may exist months or years before overt edema occurs (Stages 1-lll).
Stage I (mild): Early accumulation of fluid relatively high in protein content (e.g., in comparison with "venous" edema) which subsides with limb elevation. Pitting may occur. An increase in various types of proliferating cells may also be seen.
Stage II (moderate): Involves the permanent accumulation of pathologic solids such as fat and proteins and limb elevation alone rarely reduces tissue swelling, and pitting is manifest. Later in this stage, the limb may not pit as excess subcutaneous fat and fibrosis develop.
Stage III (severe): Encompasses lymphostatic elephantiasis where pitting can be absent and trophic skin changes such as acanthosis, alterations in skin character and thickness, further deposition of fat and fibrosis, and warty overgrowths have developed. It should be noted that a limb may exhibit more than one stage, which may reflect alterations in different lymphatic territories.

The detection of grade 0 lymphedema is problematic and may be present for months or years without physical manifestation. Optimally, the "at risk" limb is tested pre- and postsurgery (e.g., mastectomy or lumpectomy with lymph node dissection) using bioimpedance spectroscopy (BIS). BIS (i.e., impedance plethysmography) is a measure of the resistance met by a current passed through the skin via electrodes. The difference between the readings pre- and postsurgery is proposed to determine the presence or lack of lymphedema.

PRACTICE GUIDELINES AND POSITION STATEMENTS

NATIONAL COMPREHENSIVE CANCER NETWORK

The NCCN Clinical Practice Guidelines on Survivorship (v.2.2025) recommends that survivors at risk for lymphedema should be regularly screened for lymphedema by symptom assessment, clinical examination, and, if available, bioimpedance spectroscopy. NCCN notes that survivors who had surgery, radiation, or chemoradiation to the axillary, supraclavicular, cervical, or pelvic inguinal lymph node system are at risk. While sentinel node biopsy also increases risk of lymphedema, it poses less risk than complete dissection. Other factors increasing risk of lymphedema development include body mass index of 30 kg/m² or higher, localized infection, increased number of nodes removed, and higher initial extent of disease.

NCCN Clinical Practice Guidelines on Breast Cancer (v.4.2025) recommend education, monitoring, and referral for lymphedema management as needed. For further information, see the Survivorship Guidelines.

References

Barrio AV, Eaton A, Frazier TG. A Prospective Validation Study of Bioimpedance with Volume Displacement in Early-Stage Breast Cancer Patients at Risk for Lymphedema. Ann Surg Oncol. 2015;22 Suppl 3:S370-5.

Blaney JM, McCollum G, Lorimer J, et al. Prospective surveillance of breast cancer-related lymphoedema in the first-year post-surgery: feasibility and comparison of screening measures. Support Care Cancer. 2015;23(6):1549-1559.

Boccardo FM, Ansaldi F, Bellini C, et al. Prospective evaluation of a prevention protocol for lymphedema following surgery for breast cancer. Lymphology. 2009;41(1):1-9.

Cornish BH, Chapman M, Hirst C, et al. Early diagnosis of lymphedema using multiple frequency bioimpedance. Lymphology. 2001;34(1):2-11.

Czerniec SA, Ward LC, Refshauge KM, et al. Assessment of breast cancer-related arm lymphedema: comparison of physical measurement methods and self-report. Cancer Invest. 2010;28(1):54-62.

DiSipio T, Rye S, Newman B, et al. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. 2013;14(6):500-15.

Erdogan Iyigun Z, Selamoglu D, Alco G, et al. Bioelectrical impedance for detecting and monitoring lymphedema in patients with breast cancer. Preliminary results of the florence nightingale breast study group. Lymphat Res Biol. 2015;13(1):40-5.

Hayes S, Janda M, Cornish B, et al. Lymphedema secondary to breast cancer: how choice of measure influences diagnosis, prevalaence, and identifiable risk factors. Lymphology. 2008;41(1):18-28.

International Society of Lymphology Executive Committee. The Diagnosis and Treatment of Peripheral Lymphedema: 2023 Consensus Document of the International Society of Lymphology. 2023. Available at: https://journals.librarypublishing.arizona.edu/lymph/article/id/6372/. Accessed August 25, 2025.

Jeffers EJ, Wagner JL, Korentager SS, et al. Breast Cancer-Related Lymphedema (BCRL) and Bioimpedance Spectroscopy: Long-Term Follow-Up, Surveillance Recommendations, and Multidisciplinary Risk Factors. Ann Surg Oncol. 2023;30(10):6258-6265.

Kaufman DI, Shah C, Vicini FA, et al. Utilization of bioimpedance spectroscopy in the prevention of chronic breast cancer-related lymphedema. Breast Cancer Res Treat. 2017;166(3):809-815.

Kilgore LJ, Korentager SS, Hangge AN, et al. Reducing Breast Cancer-Related Lymphedema (BCRL) Through Prospective Surveillance Monitoring Using Bioimpedance Spectroscopy (BIS) and Patient Directed Self-Interventions. Ann Surg Oncol. 2018;25(10):2948-2952.

Koelmeyer LA, Borotkanics RJ, Alcorso J, et al. Early surveillance is associated with less incidence and severity of breast cancer-related lymphedema compared with a traditional referral model of care. Cancer. 2019;125(6):854-862.

Laidley A, Anglin B. The Impact of L-Dex(®) Measurements in Assessing Breast Cancer-Related Lymphedema as Part of Routine Clinical Practice. Front Oncol. 2016;6:192.

Lim SM, Han Y, Kim SI, et al. Utilization of bioelectrical impedance analysis for detection of lymphedema in breast Cancer survivors: a prospective cross sectional study. BMC Cancer. 2019;19(1):669.

Mehrara B, Ashinoff RL, Chang, EI. Clinical features, diagnosis, and staging of peripheral lymphedema. 02/04/2025. Up to Date. [UpToDate Web site]. Available at: http://www.uptodate.com/home/index.html. [via subscription only]. Accessed August 25, 2025.

National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology: Breast Cancer. Version 4.2025. Available at: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed August 25, 2025.

National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology: Survivorship. Version 2.2025. Available at: https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf. Accessed August 25, 2025.

Oremus M, Walker K, Dayes I, et al. Diagnosis and treatment of secondary lymphedema. Agency for Healthcare Research and Quality (AHRQ) [technology assessment]. May 28. 2010. Available at: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id66aTA.pdf. Accessed August 25, 2025.

Pusic AL, Cemal Y, Albornoz C, et al. Quality of life among breast cancer patients with lymphedema: a systematic review of patient-reported outcome instruments and outcomes. J Cancer Surviv. 2013;7(1):83-92.

Ridner SH, Dietrich MS, Cowher MS, et al. A Randomized Trial Evaluating Bioimpedance Spectroscopy Versus Tape Measurement for the Prevention of Lymphedema Following Treatment for Breast Cancer: Interim Analysis. Ann Surg Oncol. 2019;26(10):3250-3259.

Ridner SH, Dietrich MS, Boyages J, et al. A Comparison of Bioimpedance Spectroscopy or Tape Measure Triggered Compression Intervention in Chronic Breast Cancer Lymphedema Prevention. Lymphat Res Biol. 2022;20(6):618-628.

Shah C, Arthur DW, Wazer D, et al. The impact of early detection and intervention of breast cancer-related lymphedema: a systematic review. Cancer Med. 2016;5(6):1154-1162.

Shah C, Boyages J, Koelmeyer L, et al. Timing of Breast Cancer Related Lymphedema Development Over 3 Years: Observations from a Large, Prospective Randomized Screening Trial Comparing Bioimpedance Spectroscopy (BIS) Versus Tape Measure. Ann Surg Oncol. 2024;31(11):7487-7495.

Shah C, Vicini F, Beitsch P, et al. The use of bioimpedance spectroscopy to monitor therapeutic intervention in patients treated for breast cancer related lymphedema. Lymphology. 2013;46(4):184-92.

Smoot BJ, Wong JF, Dodd MJ. Comparison of diagnostic accuracy of clinical measures of breast cancer-related lymphedema: area under the curve. Arch Phys Med Rehabil. 2011; 92(4):603-610.

Soran A, Ozmen T, McGuire KP, et al. The importance of detection of subclinical lymphedema for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection; a prospective observational study. Lymphat Res Biol. 2014;12(4):289-294.

Stout Gergich NL, Pfalzer LA, McGarvey C, et al. Pre-operative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer. 2008;112(12):2809-2819.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. IMP XCA with lymphodema analysis PC software. 510(k) summary. [FDA Web site]. 03/27/2007. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf5/K050415.pdf. Accessed August 25, 2025.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Impedimed LDex U400. 510(k) summary. [FDA Web site]. 10/03/2008. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf8/K080825.pdf. Accessed August 25, 2025.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. SOZO. 510(k) summary. [FDA Web site]. 08/11/2017. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf17/K172122.pdf. Accessed August 25, 2025.

Vicini F, Shah C, Lyden M, et al. Bioelectrical impedance for detecting and monitoring patients for the development of upper limb lymphedema in the clinic. Clin Breast Cancer. 2012; 12(2):133-137.

Ward LC, Dylke E, Czerniec S, et al. Confirmation of the reference impedance ratios used for assessment of breast cancer-related lymphedema by bioelectrical impedance spectroscopy. Lymphat Res Biol. 2011;9(1):47-51.

Warren AG, Janz BA, Slavin SA, et al. The use of bioimpedance analysis to evaluate lymphedema. Ann Plast Surg. 2007;58(5):541-543.

Whitworth P, Vicini F, Valente SA, et al. Reducing rates of chronic breast cancer-related lymphedema with screening and early intervention: an update of recent data. J Cancer Surviv. 2024;18(2):344-351.

Whitworth PW, Cooper A. Reducing chronic breast cancer-related lymphedema utilizing a program of prospective surveillance with bioimpedance spectroscopy. Breast J. 2018;24(1):62-65.

Whitworth PW, Shah C, Vicini F, et al. Preventing Breast Cancer-Related Lymphedema in High-Risk Patients: The Impact of a Structured Surveillance Protocol Using Bioimpedance Spectroscopy. Front Oncol. 2018;8:197.

Coding

CPT Procedure Code Number(s)

THE FOLLOWING CODE REPRESENTS THE DETECTION OF LYMPHEDEMA:

93702

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

I89.0 Lymphedema, not elsewhere classified

I97.2 Postmastectomy lymphedema syndrome

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

11/17/2025

Version Issued Date: