Medical Policy

Policy Num:       02.001.048
Policy Name:     Bioimpedance Devices for Detection and Management of Lymphedema 

Policy ID:          [02.001.048]  [Ac / B / M+ / P+]  [2.01.82]

Last Review:       August 07, 2025
Next Review:       August 20, 2026
 

Related Policies:

08.001.029 - Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers

07.001.119 - Surgical Treatments for Breast Cancer-Related Lymphedema

07.001.164    Liposuction for Lipedema and Lymphedema

 Bioimpedance Devices for Detection and Management of Lymphedema

Summary

Description

Secondary lymphedema may develop following treatment for breast cancer. Bioimpedance, which uses resistance to electrical current to compare the composition of fluid compartments, could be used as a tool to diagnose lymphedema.

Summary of Evidence

For individuals who have known or suspected lymphedema who receive bioimpedance spectroscopy, the evidence includes systematic reviews, 1 randomized controlled trial (RCT), 1 prospective comparative observational study, and multiple uncontrolled observational studies. Relevant outcomes are test validity, symptoms, and quality of life. Diagnostic accuracy studies have found a poor correlation between bioimpedance analysis and the reference standard (volume displacement or circumferential measurement). Results from the PREVENT RCT comparing bioimpedance with standard tape measure following treatment for breast cancer have been published. At a median follow-up of 32.9 months, BIS patients triggered intervention at a lower rate than tape measured patients (20.1% vs 27.5%) and fewer patients progressed in this group (7.9% vs 19.2%). The RCT was limited by its open-label design and lack of reporting of important health outcomes. The single prospective comparative study found a significantly lower rate of clinical lymphedema in patients managed with BIS devices but had several limitations, including nonrandomized design, lack of blinding, lack of complete data on a substantial proportion of enrolled patients, and lack of a systematic method for diagnosing lymphedema in the control group. Retrospective studies suggested that postoperative bioimpedance monitoring is feasible but provide limited information about its efficacy. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Additional Information

2025 Input

Clinical input was sought to help determine whether the use of bioimpedance spectroscopy for individuals with lymphedema and/or lipedema would provide a clinically meaningful improvement in net health outcome and represents generally accepted medical practice in selected patients. In response to requests, clinical input was received from 3 respondents identified by the National Commission on Lymphatic Diseases (NCLD) or an academic medical center. In addition to this request, a plastic surgeon specializing in lymphedema research and reconstruction at a major academic center was interviewed.

For individuals with known or suspected (ie, clinically diagnosed or symptomatic) lymphedema, clinical input supports that use of bioimpedance spectroscopy is consistent with generally accepted medical practice. Feedback on whether this use results in a clinically meaningful improvement in net health outcome was mixed, with the primary benefit limited to situations where confirmation of maximal benefit from conservative measures such as decongestive therapy can help inform decisions around escalation of therapy. For individuals who are asymptomatic but are at elevated risk for lymphedema due to prior radiation, surgery, or trauma impacting the lymphatic system, clinical input supports that use of bioimpedance spectroscopy is consistent with generally accepted medical practice and that its clinical use is expected to provide a clinically meaningful improvement in net health outcome. Bioimpedance spectroscopy in this high-risk, asymptomatic, surveillance context can prompt early intervention and limit progression to chronic lymphedema with fibrosis.

Further details from clinical input are included in the Appendix.

Objective

The objective of this evidence review is to evaluate whether the use of bioimpedance spectroscopy devices improves the net health outcome for individuals with known or suspected lymphedema.

Policy Statements

Bioimpedance spectroscopy may be considered medically necessary to confirm a diagnosis of lymphedema in the following clinical scenario:

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

Bioimpedance spectroscopy may be considered medically necessary for surveillance of lymphedema in the following clinical scenarios:

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

2. The individual remains symptomatic following a course of conservative therapy for lymphedema, and testing would guide decisions regarding escalation of therapy (eg, liposuction, surgery) (see Policy Guidelines).

Bioimpedance spectroscopy is considered investigational outside of the aforementioned clinical scenarios.

Policy Guidelines

Medically necessary positions are based on clinical input. Additional details from clinical input are detailed in the Appendix, including addressing the role of a related diagnostic intervention - indocyanine green lymphography - largely considered by lymphedema surgeons to be the most unequivocal diagnostic tool for assessing lymphatic dysfunction and informing patient management. For individuals with clinically diagnosed and/or symptomatic lymphedema, bioimpedance spectroscopy provides limited incremental utility for the optimization of decongestive therapy - but may confirm maximal expected benefit from conservative therapies and thus inform decisions concerning treatment escalation.

An optimal surveillance frequency in individuals at high-risk for the development of secondary lymphedema has not been established. Lymphedema experts generally recommend assessments every 3-6 months for a minimum of 3 years after cancer treatment on the basis of the PREVENT RCT.

Coding

See the Codes table for details.

Benefit Application

BlueCard/National Account Issues

State or federal mandates (eg, Federal Employee Program) may dictate that certain U.S. Food and Drug Administration‒approved devices, drugs, or biologics may not be considered investigational, and thus these devices may be assessed only by their medical necessity.

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.  

Background

Lymphedema

Lymphedema is an accumulation of fluid due to disruption of lymphatic drainage. It is characterized by nonpitting swelling of an extremity or trunk, and is associated with wound healing impairment, recurrent skin infections, and decreased quality of life. Lymphedema can be caused by congenital or inherited abnormalities in the lymphatic system (primary lymphedema) but is most often caused by acquired damage to the lymphatic system (secondary lymphedema). Breast cancer treatment (surgical removal of lymph nodes and radiotherapy) is one of the most common causes of secondary lymphedema. In a systematic review of 72 studies (N=29,612 women), DiSipio et al (2013) reported that nearly 20% of breast cancer survivors will develop arm lymphedema.^1, The risk factors with robust evidence for the development of lymphedema included extensive surgical procedures (such as axillary lymph node dissection, a higher number of lymph nodes removed, and mastectomy) as well as being overweight or obese.

Diagnosis and Staging

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.

Table 1 lists International Society of Lymphology guidance for staging lymphedema (2023) based on "softness" or "firmness" of the limb and the changes with an elevation of the limb.^2,

Table 1. Recommendations for Staging Lymphedema

Management and Treatment

Lymphedema is treated using elevation, compression, and exercise. Conservative therapy may consist of several features depending on the severity of the lymphedema. Individuals are educated on the importance of self-care including hygiene practices to prevent infection, maintaining ideal body weight through diet and exercise, and limb elevation. Compression therapy consists of repeatedly applying padding and bandages or compression garments. Manual lymphatic drainage is a light pressure massage performed by trained physical therapists or by affected individuals designed to move fluid from obstructed areas into functioning lymph vessels and lymph nodes. Complete decongestive therapy is a multiphase treatment program involving all of the previously mentioned conservative treatment components at different intensities. Pneumatic compression pumps may also be considered as an adjunct to conservative therapy or as an alternative to self-manual lymphatic drainage in individuals who have difficulty performing self-manual lymphatic drainage. In individuals with more advanced lymphedema after fat deposition and tissue fibrosis has occurred, palliative surgery using reductive techniques such as liposuction may be performed.

Bioimpedance Spectroscopy

Bioimpedance spectroscopy is based on the theory that the level of opposition to the 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.

Bioimpedance has been proposed as a diagnostic test for this condition. In usual care, lymphedema is recognized clinically or via limb measurements. However, management via bioelectrical impedance spectroscopy has been proposed as a way to implement early treatment of subclinical lymphedema to potentially reduce its severity.

Regulatory Status

A selection of devices that have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process to aid in the assessment of lymphedema are summarized in Table 2. Among the FDA-approved bioimpedance devices are SOZO (ImpediMed), MoistureMeterD (Delfin Technologies), and the L-Dex U400 (ImpediMed). The L-Dex U400 was discontinued by its manufacturer in November 2018.

Table 2. FDA-Cleared Bioimpedance Spectroscopy Devices for Lymphedema

      FDA product code: OBH.  

Rationale

This evidence review was created in March 2010 and has been updated regularly with searches of the PubMed database. The most recent literature update was performed through June 16, 2025.

Evidence reviews assess whether a medical test is clinically useful. A useful test provides information to make a clinical management decision that improves the net health outcome. That is, the balance of benefits and harms is better when the test is used to manage the condition than when another test or no test is used to manage the condition.

The first step in assessing a medical test is to formulate the clinical context and purpose of the test. The test must be technically reliable, clinically valid, and clinically useful for that purpose. Evidence reviews assess the evidence on whether a test is clinically valid and clinically useful. Technical reliability is outside the scope of these reviews, and credible information on technical reliability is available from other sources.

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American]; LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflective of and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g., women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations

Population Reference No. 1

Bioimpedance Spectroscopy in Patients With Known or Suspected Lymphedema

Clinical Context and Test Purpose

The purpose of using BIS in patients who have known, or suspected lymphedema, is to inform a diagnosis of subclinical lymphedema to initiate treatment sooner than with other diagnostic methods.

The following PICO was used to select literature to inform this review.

Populations

The relevant population of interest is individuals with known or suspected lymphedema.

Interventions

The relevant intervention of interest is BIS.

Management via BIS has been proposed as a way to implement early treatment of subclinical lymphedema to potentially reduce its severity.

Comparators

The relevant comparators of interest are volume displacement and circumferential measurement.

In usual care, lymphedema is recognized clinically or via limb measurements.

Volume is measured using different methods; eg, tape measurements with geometry formulas, perometry, and water displacement.

Outcomes

Objective outcomes of interest include a reduction in limb circumference and/or volume and reduction in the rates of infections (eg, cellulitis, lymphangitis).

Patient-reported outcomes (PROs) of interest include symptoms, quality of life (QOL), and functional measures. A systematic review of PRO instruments and outcomes used to assess QOL in breast cancer patients with lymphedema, Pusic et al (2013) found that most studies included generic PRO instruments or oncology PRO instruments.^3, Lymphedema-specific instruments are occasionally used; specifically, the Upper Limb Lymphedema 27 was found to have strong psychometric properties.

There does not appear to be a consensus on minimally clinically important change for either objective outcomes such as changes in arm volume or subjective measures such as changes to patient symptoms or QOL.

The time frame for outcomes varies from months to years after the onset of lymphedema symptoms.

Study Selection Criteria

For evaluation of clinical validity of bioimpedance testing, studies that meet the following eligibility criteria were considered:

• Reported on the accuracy of the marketed version of the technology (including any algorithms used to calculate scores)

• Included a suitable reference standard

• Patient/sample clinical characteristics were described

• Patient/sample selection criteria were described

For evaluation of clinical utility, comparative controlled prospective trials, with preference for RCTs were considered. In the absence of such trials, comparative observational studies, with preference for prospective studies were considered.

Clinically Valid

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

Systematic Review

A technology assessment on the diagnosis and treatment of secondary lymphedema, performed for the Agency for Healthcare Research and Quality (AHRQ), was published in 2010.^4, The AHRQ assessment identified 8 studies that reported the sensitivity and specificity of tests to diagnose secondary lymphedema. Reviewers noted there is no true criterion standard to grade severity of lymphedema and that limb volume and circumference are used as de facto criterion standards. Two of the 8 selected studies evaluated BIS devices.^5,6, Overall, reviewers concluded that, due largely to heterogeneity among studies, the evidence did not permit conclusions on the optimal diagnostic test for detection of secondary lymphedema.

A systematic review by Whitworth et al (2022) evaluated strategies for screening and early intervention in breast cancer patients at risk for lymphedema.^7, A total of 12 studies (N=2907) were included. Although 4 RCTs were included, only 1 RCT evaluated BIS (see Ridner et al below). Of the 7 prospective, observational studies identified, 5 evaluated BIS. Although these studies generally point to BIS as a sensitive surveillance technique, this analysis did not synthesize data from the included studies and no quality or bias risk was assessed.

Observational Studies

After the AHRQ review, several other studies have evaluated the diagnostic performance of BIS devices for detecting lymphedema. Prospective studies that compared bioelectrical impedance analysis to a reference standard are described next.

A study by Barrio et al (2015) enrolled 223 women with newly diagnosed breast cancer and a plan for unilateral axillary surgery.^8, Thirty-seven patients were excluded due to ineligibility or withdrawal, leaving a sample size of 186. Prior to surgery, participants received baseline volumetric measurements with a bioimpedance device (L-Dex) and volume displacement (the reference standard). Patients then had follow-up volumetric measurements every 3 to 6 months for 3 years. At the last follow-up (median, 18.2 months), 152 (82%) patients had no lymphedema, 21 (11%) had an abnormal L-Dex, and no lymphedema by volume displacement, 4 (2%) had an abnormal L-Dex and lymphedema by volume displacement, and 9 (5%) had lymphedema without prior L-Dex abnormality. In an analysis including only patients with at least 6 months of follow-up, L-Dex had a sensitivity of 31% (4/13) and a specificity of 88% (129/147) for predicting subsequent lymphedema development. Also, the correlation between changes in volume displacement and changes in L-Dex results were in the low-to-moderate range at 3 months (r=0.31) and 6 months (r=0.21). However, at the time of lymphedema diagnosis, the L-Dex ratio was abnormal in 12 of 13 patients (diagnostic sensitivity, 92%).

Blaney et al (2015) reported on a prospective study with 126 women with stage I, II, or III unilateral breast cancer.^9, A total of 115 women underwent baseline assessment with an L-Dex and circumferential measurement. The circumferential measurement was used as the reference standard, although the authors noted the test is an imperfect criterion standard. Postsurgical follow-up assessments were planned every 3 months for a year. The number of women completing these assessments was 109 (95%) at 3 months, 89 (77%) at 6 months, 79 (69%) at 9 months, and 71 (62%) at 12 months. Over 12 months, 31 participants were identified as having lymphedema by at least 1 of the assessment methods. Twenty-eight (90%) of 31 were identified by circumferential measurement and 11 (35%) by BIS. There was no statistically significant correlation between bioimpedance analysis and circumferential measurement.

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if individuals receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

The ideal study design is an RCT comparing health outcomes in individuals managed with and without the use of bioimpedance devices.

Randomized Controlled Trial

One multicenter, international, RCT conducted by Ridner et al (2019 and 2022) [PREVENT RCT] compared bioimpedance to volume measurements calculated from arm circumference using a tape measure (Table 3).^10,11, The primary aim of the study was to determine if subclinical detection of extracellular fluid accumulation via BIS and subsequent early intervention reduces the rate of progression to clinical lymphedema relative to the rates seen using standard tape measurements. Patients requiring early intervention were prescribed a compression sleeve and gauntlet for 4 weeks and then re-evaluated. Predetermined thresholds were used to trigger early intervention. The implementation threshold for patients in the bioimpedance group was initially a change that was ≥10 L-Dex units (3 standard deviations) higher than the presurgical baseline measure, but the protocol was changed in 2016 to include all patients with ≥6 L-Dex units. Patients in the tape measure group triggered when they had a volume change in the at-risk arm that was between >5 and <10% above the presurgical baselines. Progression to clinical lymphedema was defined as a 10% or greater increase in tape measure volume from baseline in the at-risk arm.

Results of the interim analysis and final analysis are summarized in Table 4.^10,11, At interim analysis , 109 of 508 (21.9%) patients received early intervention due to reaching the pre-determined threshold. Patients randomized to bioimpedance had a lower rate of trigger and longer times to trigger. A total of 12 triggering patients progressed to clinical lymphedema (10 in the TM group [14.7%] and 2 in the BIS group [4.9%]). The difference between groups was not statistically significant (p=.130) and did not meet stopping criteria specified in the study protocol. At final analysis (median of 32.9 months follow-up), BIS triggered an intervention at a lower rate than TM patients (20.1% vs 27.5%; p=.011); however, fewer patients in the BIS group progressed compared with tape measure (7.9% vs 19.2%; relative risk, 0.41; 95% CI, 2.8-4.5; p=.001).

This study had several limitations (see Tables 5 and 6), including an open-label design, which may have introduced bias in outcome assessment, treatments, or the decision to trigger an intervention. Important health outcomes such as patient-reported symptoms, QOL, and function were not assessed. Additionally, 39 patients who progressed prior to an intervention being triggered were excluded from the analysis.

Shah et al. (2024) conducted a secondary analysis on data from the PREVENT RCT to investigate the onset and progression of subclinical breast cancer-related lymphedema (sBCRL) and clinical breast cancer-related lymphedema (cBCRL).^12,The aim was to provide guidance on the optimal screening frequency and duration for BCRL. A cohort of 919 women at risk of developing cBCRL were regularly screened using either bioimpedance or tape measure (TM) for up to 36 months following their breast cancer treatment. Women at risk of cBCRL (N=919) were regularly screened for up to 36 months post breast cancer treatment using either bioimpedance or TM. In total, 209 patients (23%) developed sBCRL (bioimpedance: n=89, TM: n=120) and were eligible for intervention. Subsequently, 30 patients progressed to cBCRL post-intervention (BIS: 7, TM: 23). More than half of the patients exhibited measurements consistent with sBCRL within 9 months of breast cancer treatment. Initial detections of sBCRL persisted, regardless of the screening method used, with rates remaining stable in the second and third years (p>0.24) post-surgery. Furthermore, 39 patients progressed to cBCRL without previously developing sBCRL or receiving intervention over the 3-year period. The timing of sBCRL detection highlights that patients remain at risk years after treatment and may continue to progress to cBCRL long after surgery. Early detection of sBCRL facilitates timely intervention, thereby reducing the likelihood of progression to cBCRL. Consequently, patients should be diligently monitored for a minimum of 3 years following the completion of cancer treatment, with particular emphasis on focused and targeted monitoring during the initial 9-month period.

      BIS: bioimpedance spectroscopy; DCIS: ductal carcinoma in situ; NCT: national clinical trial; PREVENT: Bioimpedance Spectroscopy Versus Tape Measure in Prevention of Lymphedema; RCT: randomized controlled trial.

Table 4. Summary of Key RCT Results

      BIS: bioimpedance spectroscopy; IQR: interquartile range; RCT: randomized controlled trial.

Table 5. Study Relevance Limitations

      The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment. a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use. b Intervention key: 1. Classification thresholds not defined; 2. Version used unclear; 3. Not intervention of interest. c Comparator key: 1. Classification thresholds not defined; 2. Not compared to credible reference standard; 3. Not compared to other tests in use for same purpose. d Outcomes key: 1. Study does not directly assess a key health outcome; 2. Evidence chain or decision model not explicated; 3. Key clinical validity outcomes not reported (sensitivity, specificity, and predictive values); 4. Reclassification of diagnostic or risk categories not reported; 5. Adverse events of the test not described (excluding minor discomforts and inconvenience of venipuncture or noninvasive tests). e Follow-Up key: 1. Follow-up duration not sufficient with respect to natural history of disease (true-positives, true-negatives, false-positives, false-negatives cannot be determined).

Table 6. Study Design and Conduct Limitations

      The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment. a Selection key: 1. Selection not described; 2. Selection not random or consecutive (ie, convenience). b Blinding key: 1. Not blinded to results of reference or other comparator tests. c Test Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described. d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication. e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data. f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported. 

Observational Studies

One prospective observational study compared clinical lymphedema rates in patients managed with and without bioimpedance analysis. This study, by Soran et al (2014), involved prospective detection of subclinical lymphedema in 186 women with breast cancer managed with L-Dex or tape measurement of limb circumference.^13, Measurements were obtained at baseline and 3- to 6-month intervals for 5 years. Subclinical lymphedema was defined as an L-Dex value outside the normal range, or that increased at least 10 units from baseline. Patients diagnosed with subclinical lymphedema were treated with, eg, short-term physical therapy, compression garments, and received education on exercise and limb elevation. A total of 180 women were included in the analysis. Seventy-two women had both preoperative and postoperative bioimpedance and tape measurements (preoperative group). Forty-four women had preoperative bioimpedance and tape measurements but only had tape measurements postoperatively (control group). The remaining 64 women had postoperative bioimpedance and tape measurements, but no preoperative measurements (no preoperative group). The authors compared the demographic and clinical characteristics of the preoperative and control groups and the preoperative and postoperative groups; they did not identify any statistically significant differences.

In the preoperative group, 28 (36%) of 72 women were diagnosed with subclinical lymphedema and referred for treatment; 2 women progressed to clinical lymphedema. In the control group, 16 women (36%) developed clinical lymphedema during follow-up. Limitations of the study included a lack of an alternative method for detecting subclinical lymphedema in women in the control group so that they could receive treatment early; a lack of randomization to a treatment group; and incomplete data on pre- and postoperative measures of lymphedema except in a subset of the total population.

Multiple uncontrolled observational studies have reported rates of lymphedema identified through surveillance with bioimpedance in women at high-risk following breast cancer treatment.^{14,15,16,17,18,19,20,21,22,23,} Because these studies did not include a comparison group of women who received usual care or alternative methods of screening, they do not provide evidence to draw conclusions about the clinical utility of bioimpedance.

Section Summary: Bioimpedance Spectroscopy in Individuals With Known or Suspected Lymphedema

Diagnostic accuracy studies have found a poor correlation between bioimpedance analysis and the reference standard (volume displacement or circumferential measurement). Results from the PREVENT RCT (2019, 2022) comparing bioimpedance with standard tape measure following treatment for breast cancer have been published. At a median follow-up of 32.9 months, BIS patients triggered intervention at a lower rate than tape measured patients (20.1% vs 27.5%) and fewer patients progressed in this group (7.9% vs 19.2%). The RCT was limited by its open-label design and lack of reporting of important health outcomes. The single prospective comparative study found a significantly lower rate of clinical lymphedema in patients managed with BIS devices but had several limitations, including nonrandomized design, lack of blinding, lack of complete data on a substantial proportion of enrolled patients, and lack of a systematic method for diagnosing lymphedema in the control group. Retrospective studies suggested that postoperative bioimpedance monitoring is feasible but provide limited information about its efficacy. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Summary of Evidence

For individuals who have known or suspected lymphedema who receive bioimpedance spectroscopy (BIS), the evidence includes systematic reviews, 1 randomized controlled trial (RCT), 1 prospective comparative observational study, and multiple uncontrolled observational studies. Relevant outcomes are test validity, symptoms, and quality of life. Diagnostic accuracy studies have found a poor correlation between bioimpedance analysis and the reference standard (volume displacement or circumferential measurement). Results from the PREVENT RCT comparing bioimpedance with standard tape measure following treatment for breast cancer have been published. At a median follow-up of 32.9 months, BIS patients triggered intervention at a lower rate than tape measured patients (20.1% vs 27.5%) and fewer patients progressed in this group (7.9% vs 19.2%). The RCT was limited by its open-label design and lack of reporting of important health outcomes. The single prospective comparative study found a significantly lower rate of clinical lymphedema in patients managed with BIS devices but had several limitations, including nonrandomized design, lack of blinding, lack of complete data on a substantial proportion of enrolled patients, and lack of a systematic method for diagnosing lymphedema in the control group. Retrospective studies suggested that postoperative bioimpedance monitoring is feasible but provide limited information about its efficacy. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Supplemental Information

The purpose of the remaining sections in Supplemental Information is to provide reference material regarding existing practice guidelines and position statements, U.S. Preventive Services Task Force Recommendations and Medicare National Coverage Decisions and registered, ongoing clinical trials. Inclusion in the Supplemental Information does not imply endorsement and information may not necessarily be used in formulating the evidence review conclusions.

Clinical Input From Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

2025 Input

In response to requests, clinical input was received from 3 respondents identified by the National Commission on Lymphatic Diseases (NCLD) or an academic medical center. In addition to this request, a plastic surgeon specializing in lymphedema research and reconstruction was interviewed.

For individuals with known or suspected (ie, clinically diagnosed or symptomatic) lymphedema, clinical input supports that use of bioimpedance spectroscopy is consistent with generally accepted medical practice. Feedback on whether this use results in a clinically meaningful improvement in net health outcome was mixed, with the primary benefit limited to situations where confirmation of maximal benefit from conservative measures such as decongestive therapy can help inform decisions around escalation of therapy. For individuals who are asymptomatic but are at elevated risk for lymphedema due to prior radiation, surgery, or trauma impacting the lymphatic system, clinical input supports that use of bioimpedance spectroscopy is consistent with generally accepted medical practice and that its clinical use is expected to provide a clinically meaningful improvement in net health outcome. Bioimpedance spectroscopy in this high-risk, surveillance context can prompt early intervention and limit progression to chronic, irreversible lymphedema with fibrosis.

Further details from clinical input are included in the Appendix.

Practice Guidelines and Position Statements

Guidelines or position statements will be considered for inclusion in ‘Supplemental Information’ if they were issued by, or jointly by, a US professional society, an international society with US representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

National Comprehensive Cancer Network

National Comprehensive Cancer Network (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 exam, and, if available, bioimpedance spectroscopy.^24,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 BMI ≥ 30 kg/m², 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 they refer the reader to the Survivorship Guidelines.^25,

U.S. Preventive Services Task Force Recommendations

Not applicable.

Medicare National Coverage

There is no national coverage determination. In the absence of a national coverage determination, coverage decisions are left to the discretion of local Medicare carriers.

Ongoing and Unpublished Clinical Trials

Some currently ongoing and unpublished trials that might influence this review are listed in Table 7.

Table 7. Summary of Key Trials

      a Denotes industry-sponsored or cosponsored trial; BIS: bioimpedance spectroscopy; NCT: national clinical trial.  

References

1. DiSipio T, Rye S, Newman B, et al. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. May 2013; 14(6): 500-15. PMID 23540561
2. International Society of Lymphology Executive Committee. The Diagnosis and Treatment of Peripheral Lymphedema: 2023 Consensus Document of the International Society of Lymphology. 2023; https://journals.librarypublishing.arizona.edu/lymph/article/id/6372/. Accessed June 16, 2025.
3. 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. Mar 2013; 7(1): 83-92. PMID 23212603
4. Oremus M, Walker K, Dayes I, et al. Technology Assessment: Diagnosis and treatment of secondary lymphedema. Rockville, MD: Agency for Healthcare Research and Quality; 2010.
5. Cornish BH, Chapman M, Hirst C, et al. Early diagnosis of lymphedema using multiple frequency bioimpedance. Lymphology. Mar 2001; 34(1): 2-11. PMID 11307661
6. Hayes S, Janda M, Cornish B, et al. Lymphedema secondary to breast cancer: how choice of measure influences diagnosis, prevalence, and identifiable risk factors. Lymphology. Mar 2008; 41(1): 18-28. PMID 18581955
7. 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. Apr 2024; 18(2): 344-351. PMID 35947288
8. 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. Dec 2015; 22 Suppl 3(0 3): S370-5. PMID 26085222
9. 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. Jun 2015; 23(6): 1549-59. PMID 25398360
10. 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. Oct 2019; 26(10): 3250-3259. PMID 31054038
11. 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. Dec 2022; 20(6): 618-628. PMID 35099283
12. 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. Oct 2024; 31(11): 7487-7495. PMID 38965099
13. 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. Dec 2014; 12(4): 289-94. PMID 25495384
14. 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. PMID 27656420
15. 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. Mar 15 2019; 125(6): 854-862. PMID 30521080
16. 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. Oct 2018; 25(10): 2948-2952. PMID 29987599
17. Whitworth PW, Cooper A. Reducing chronic breast cancer-related lymphedema utilizing a program of prospective surveillance with bioimpedance spectroscopy. Breast J. Jan 2018; 24(1): 62-65. PMID 29063664
18. 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. Mar 2015; 13(1): 40-5. PMID 25526543
19. 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. Dec 2013; 46(4): 184-92. PMID 25141461
20. 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. Jul 08 2019; 19(1): 669. PMID 31286884
21. 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. Dec 2017; 166(3): 809-815. PMID 28831632
22. 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. PMID 29946531
23. 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. Oct 2023; 30(10): 6258-6265. PMID 37535267
24. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology: Survivorship. Version 2.2025. Updated May 23, 2025. https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf. Accessed June 17, 2025.
25. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology: Breast Cancer. Version 4.2025. Updated April 17, 2025. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed June 16, 2025.

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