Below is a valuable list of Gotchas!, Catch-22, Carrier-Specific Rules, and confusing, ambiguous, and contradictory Carrier guidelines and policies. This is kind of advanced but worth your time–especially if denied. I would argue it’s best to review before you file your claim.
| 1 | WHAT IS A GOTCHA! ? | A Gotcha List is a list of all the gray areas regarding reimbursement for liposuction for lipedema. These are issues where a simple Yes or No is not adequate. Most are very subjective. Most are open to interpretation. If you ask 10 consultants what the answer is you will get at least three answers (YES/NO/MAYBE). If they are certain of their answer–beware! Also included are Catch-22 issues where succeeding at one goal creates another problem. |
| 2 | PRE-AUTHORIZATION | Most surgeons will not apply for the pre-authorization without a scheduled surgery date and an up-front deposit. This is a unique situation to this surgery. A quick turnaround would be three-weeks. But some insurance carriers could take three-months to approve. The recomendation is to schedule the surgery out more than three weeks. Be sure to have all your photos and documentation before you plan the surgery–and know exactly who will send what and how they will send it (e.g., photos). |
| 3 | INCONSISTENT APPROVALS | Mary Sue, who just had surgery from the same doctor, was approved, yet yours was denied and everything looked about the same. Sometimes it matters who the insurance representative is. Some may just rubber stamp the claim, another may be in more of a denial mood. One claim may be approved with minimal documentation and another denied with everything perfect. Without an official policy you can expect inconsistent approvals and denials. |
| 4 | EASY OR HARD | Do you leave out documentation expecting the case to be easy and decide to include it only if you need to appeal? That is up to you. I prefer making your case the most compelling up-front. |
| 5 | WAIT! | Do not contact the insurance company for pre-authorization until you have all your documentation, where it is and who will send it and how. Example are photographs. (got it?). |
| 6 | TOO MUCH INFO ! | Do I really need all this information? My strategy is the more information up front, the better; If the insurance company gets a sense you know your rights, the case is compelling, and know what you are doing, they will cave. If they get a sense they can deny the claim and avoid paying, they will. |
| 7 | MEDICAL NECESSITY | There are two versions of medical necessity. One is that the procedure is reconstructive and considered to be safe and effective. That encompasses several issues including E/I/U, co-morbidities, and the strength of the research proving its effective. The other is that the patient is too sick to tolerate the procedure. The denial reason will be the same but the appeal arguments are different and they address completely different issues. |
| 8 | FILE EVEN IF DENIED | Send whatever you have and can get. Remember that if the pre-authorization is denied, you must file anyway and be prepared for a fight with appeals. |
| 9 | ASSUME NOTHING | Don’t assume anything is being done; check with everyone every week or two. Information gets lost all the time! The insurance company will often tell you they did not receive something you sent them. Don’t worry about being pushy or a pest or repeating yourself. That is your job! Work on being extra nice and expect the runaound and account reps that don’t want to be bothered with a complex case. It will be stressful. Focus on being relaxed and patient. |
| 10 | BE NICE BUT FIRM | Always get the name of everyone you speak with at the insurance company. Ask for e-mails; most insurance representatives won’t give them out but try anyway. |
| 11 | PAYMENT UP-FRONT | Most surgeons require payment up-front before pre-authorization and approval even if they agree to assist with filing your claim. Some will require payment and a surgery date before they write you an Expert Opinion Letter. That is a Catch-22 because some pre-authorizations take months, not weeks. |
| 12 | NO FEE SCHEDULE | There are no fee schedules for liposuction surgery (reimbursement can be any amount; case by case). Medicare does not assign RVU’s to the four liposuction CPT codes. This means that they are excluded from payment but that is not always the case as some single case reimbursements from Medicare have been reported. The Gotcha is that many surgeons don’t want a Medicare fee schedule! The current private pay fee is much higher than what Medicare traditionally charges for similar procedures. The professional societies are not interested in lobbying for a reconstructive, lymph-sparing or tumescent liposuction for lipedema code. This is also a Catch-22 issue. Not being in the fee schedule is a problem but if there was an established fee schedule–must less than the going cash price, most surgeons may not accept it. |
| 13 | NOT CONTRACTED | Many liposuction for lipedema experts are not contracted with insurance companies and out-of-network. At best you can get an Singe Case Agreement or ask the insurance company pay you directly. |
| 14 | NORMAL WEIGHT | If you are a normal-weight patient, the insuror may request you wait for the surgery. Your photos may not be as dramatic. Emphasize pain and any impact on your ability to exercise and maintain your weight. In addition, you may need to reference research that illustrates that liposuction is effective at early stages. |
| 15 | MORBID OBESITY | Morbid obesity may be considered a co-morbidity and needs to be addressed. You could be at an advanced stage, a malformed appearance, with numerous functionality and Quality of Life Problems but too sick for the operation. That’s a CATCH-22. |
| 16 | DENIAL REASON | Pay special attention to the denial reason. Some might say it’s “cosmetic” others “not medically necessary” or it’s “investigational, experimental or unproven.” Each of those is related but slightly different. |
| 17 | TOO SICK | If the patient has an advanced stage, lipolymphedema, morbid obesity and has extremely limited functionality and mobility the reconstructive nature is strong but may be too sick to tolerate the procedure. That’s Catch 22. |
| 18 | SINGLE CASE AGREEMENT | If your surgeon is out-of-network you may need to negotiate a Single Case Agreement (SCA). The SCA outlines the procedure, the number of treatments and payment amount. The carrier will pay the (non-contracted) clinic on a single-case basis. The Gotcha! is that your surgeon may not accept the SCA amount. |
| 19 | ADVOCATE OR NOT? | Should you pay for a reimbursement advocate? In Sep. 2020, the issue is that the time involved in obtaining payment can be moderate or extreme. Therefore it is difficult for an experienced Advocate to be able to work every aspect of the reimbursement process for a fair rate. Therefore you must assume as much responsibility as you can. See my Advocate question list on the website. |
| 20 | COVER LETTER | As the patient you can include a cover letter. It should read like a Table of Contents listing what you have provided. It is okay to include a short description of your condition but it should not substitute for Provider notes. If you don’t have the Provider documentation I recommend, you can include the information in the cover letter but the insurance company may ignore it. While better than nothing, there is a danger that the ins. co. may question why the managing physician did not document that conservative measures were ineffective, for example. |
| 21 | DENIALS | Approvals and denials can take weeks, months or even years! Some ins. Co may approve in 3 weeks. Others may take months. Once denied, the review process may take many months; three to nine months. If there are multiple appeals the process could take longer than a year. Medicare has five official levels. |
| 22 | LIPEDEMA STAGES | Listing and focusing on the Lipedema stage. Some reimbursement consultants feel that listing the stage could cause a denial of the early stages. You are providing more specific information but it could hurt you if the carrier is inclined to deny the claim. That’s a Catch-22. |
| 23 | NO ICD-10-CM Code | There is not a specific ICD-10-CM lipedema code. Most use R60.9 but it is simply listed as “Edema.” |
| 24 | SIX MONTHS DOCO | Begin collecting Provider documentation 6 months or more in advance. |
| 25 | NOT BOARD-CERTIFIED | Many liposuction for lipedema experts are not not board-certified plastic surgeons. |
| 26 | NO EXPERIENCE | Many insurance companies recommend board-certified plastic surgeons, who perform relatively few liposuction for lipedema operations (as a percent of their total output). The agent does not understand the difference between cosmetic liposuction and reconstructive liposuction. |
| 27 | OUT-OF-NETWORK | Is the surgeon in network or out? (Most likely your surgeon is not contracted with the carrier and out-of-network). |
| 28 | CPT CODES | The four CPT codes are listed as “suction-assisted lipectomy” by body part. This is a very generic description and you will be making that case that your procedure is different from costmetic–which would use the same codes! This is a CATCH-22. If you make your case well enough that lymph-sparing, tumescent liposuction is different from generic suction-assisted or “cosmetic” liposuction the insurance company could determine the code is not appropriate and you will need to submit an unlisted CPT code for the procedure. This is done so it’s not a dead end. You can still be reimbursed but it takes more effort to be reimbursed for an unlisted code. |
| 29 | IN-NETWORK SURGEON | The plan may recommend an in-network board-certified plastic surgeon with no lipedema experience. You might be approved but the insurance will assign the nearest in-network plastic surgeon assuming he/she can perform the surgery. Perhaps they list liposuction in their list of specialities. You will need to inform the carrier that liposuction for lipedema is a much more complicated, time-consuming procedure that requires specifica skills (lymph-sparing, tumescent liposuction) and experience (dozens and even hundreds of surgeries–specific to lipedema). |
| 30 | REQUEST EXCEPTION | Specifically request an “out-of-network” exception so they pay in-network fees. |
| 31 | NUMBER OF TX | Establish number of treatments (TX) and that the ins. co. will reimburse. |
| 32 | PHOTOS | Send Photos with pre-auth info. Determine how best to deliver them to the insurance company. The Gotcha is if you’re normal weight or they are not very persuasive. |
| 33 | NOT SUCTION-ASSISTED LIPOSUCTION | The argument is that the procedure is not SAL but more complicated; if the insurance agent makes an issue of this (you cannot use the code and then argue that it’s not accurate or appropriate) and you cannot get around it, then you would need to use an unlisted CPT™ code: 38999 (unlisted procedure, hemic or lymphatic system). This creates more problems but is not unsurmountable. |
| 34 | LOGISTICS | Logistics with the surgeons office are a main hurdle. Many cosmetic surgeons are not contracted with any insurance companies. Many don’t have practice management billing systems. You are on your own and the staff won’t have the knowledge or experience to help you. |
| 35 | PATIENT FILE CLAIM | If clinic does not file the claim you will need to submit the insurance claim. If the ins. co. agrees to pay the clinic (per SCA), submit CMS-1500 form; patient pay is the CMS-1490 form. |
| 36 | SIX MONTHS DOCO | What to do if the surgery is scheduled and you don’t have all your information? My inclination is if you don’t have the basic documenation would be to postpone the surgery until you have your six months of conservative measures documented properly and most importantly–they were ineffective. |
| 37 | CONSERVATIVE MEASURES WERE SUCESSFULL | A catch-22 is when you have good Provider documentation stating that all conservative treatments have been followed but there are no status notes or the assessment was that the treatments were working as expected. If there is not sufficient documentation that the measures failed and the progression of the disease will worsen without surgical treatment the claim may be denied. |
| 38 | EXTERNAL REVIEW BOARD | Some ins. Co. will send your claim to an External Review Board. This may increase the approval time. Also some Review Boards are quick to deny the claim. |