There are over 300 research studies regarding lipedema. There are over forty, peer-reviewed journal articles reviewing the benefits, efficacy, and safety of tumescent, lymph-sparing liposuction as the only surgical treatment for lipedema. For a lay person the most daunting task is knowing which research is considered most scientifically sound and helps make your case for medical necessity. Lipoforlipedeareimbursement.com will be collecting, ranking and organizing research so you can use it. Below is valuable strategic information on how to approach denials based on inadequate research.
Below is a list of the most common design flaws used by insurance companies and independent review boards (IRB’s) to deny a procedure as experimental investigational, or unproven and not medically necessary.
- Small sample size.
- Lack of comparison groups.
- Limited follow up duration.
- Variation in number of patients with data at each time point.
- Substantial follow-up attrition.
- Reduction in the utilization of inpatient hospital services for more invasive procedures not illustrated.
- Reduced future services not illustrated.
- Controversial or inconsistent outcomes.
- Eliminated: studies with <21 patients
- Eliminated: case reports, conference abstracts, editorial, notes, and comments.
- The literature was not peer-reviewed, published evidence.
- The precision, directness, and consistency of data did not support medical necessity (efficacy).
- The applicability of the data to general practice was not established.
Don’t be overwhelmed. My goal is to sort and organize the research so you don’t have to wade through hundreds of pages of literature. Our goal is to continually update the information as we learn of both denials and approvals. The key to success is specific dates, specific insurance companies and plans, specific outcomes (how many appeals), and what do we think made the difference? Ranking information and providing it in a .txt or .xls format is essential to making it easier to appeal and win. Some information and research is useless and a lot of reimbursement advice on the Internet is simply incorrect.
Each state may have specific rules concerning what is determined to be reconstructive versus cosmetic. For example, both breast reconstruction surgery and cleft palate are protected by federal (breast reconstruction) and state (cleft palate repair) laws. Therefore, if you’re in a state that requires reimbursement for cleft palate as reconstructive, then it’s a state law and no longer a carrier option. Note that you must mee their strict documentation and risk guidelines. To my knowledge [MAR 2020] there are no state or federal guidelines concerning LS-TL for lipedema. This needs to change.
As of the time of this writing the largest insurance group reimbursing LS-TL for lipedema as medically necessary and reconstructive is Anthem-Blue Cross NC00009). This policy covers 14 states as well as Amerigroup, an Anthem subsidiary providing Medicare Part-C and Medicaid services in the following six states: Arizona, New Jersey, New Mexico, Tennessee, Texas, and Washington. We have numerous reports of other payments but a severe lack of detail concerning which carriers, dates, and circumstances.
Check back often as we will be updating all of the information on this website often [MAR 2020]. Currently the best list of research papers and books is on the Lipedema Foundation Website
https://www.lipedema.org/books-and-papers
There is an Excel spreadsheet of over 300 papers. Yes, that is an overwhelming number and I will soon be working to create a top ten list and sort and organize by type.
The latest publication at the time of this writing (MAR 2020), is very favorable toward lymph-sparing, tumescent liposuction: Prevention of Progression of Lipedema With Liposuction Using Tumescent Local Anesthesia: Results of an International Consensus Conference.
https://www.ncbi.nlm.nih.gov/pubmed/31356433
I would look at it first.