This is included more as a thought-experiment than a proven approval technique. I don’t know if the “comparable procedure” argument would have any weight with an appeal review committee concerning reimbursement for liposuction for lipedema. I’ve not tried this strategy yet. However, if you’re working on your second or third-level appeal, it might be worth it to add this to your argument. If you use it and it works please let me know!
The bottom line is that lipedema has as at least as much, and it could be argued more of an impact on the patient’s function, gait, mobility, and Quality of Life as other procedures that the carrier currently reimburses as reconstructive and therefore medically necessary. I have listed several below. The goal here is not to diminish the impact of breast reconstruction or cleft palate repair, but to add liposuction for lipedema as a comparable procedure for an equally debilitating condition.
It has taken many years for other procedures to be accepted as reconstructive and not cosmetic. Changes in legislature are the result of advocacy and lobbying by many groups. Liposuction has a long way to go until it’s widely accepted as reconstructive for lipedema. Most of the public and many Providers are not even aware that lipedema is a separate condition from obesity. Many consider liposuction only cosmetic. This education process will take years.
Reimbursement for breast reconstruction after cancer surgery is now a federal law. That means it is no longer up to the carriers or states to determine if it is a covered procedure. It is mandated by federal law. For cleft palate repair it is mandated in at least 15 states. It is not a federal law but carriers in those states must pay.
Outside of federal and state laws each carrier can develop their own policy. Once all appeals have been exhausted without payment the patient can always file a lawsuit against the carrier for “breach of contract” (among other reasons). There are several healthcare attorneys that specialize in this sort of thing (ERISA and workman’s comp are big).
Reconstructive Liposuction: Care should be taken to refer to liposuction for lipedema as reconstructive and never cosmetic.
Comparable Treatments now considered reconstructive [DEC 2020]
Medicare Part B Breast prostheses reimbursement: Medicare Part B (Medical Insurance) covers some external breast prostheses (including a post-surgical bra) after a mastectomy. Part A covers surgically implanted breast prostheses after a mastectomy if the surgery takes place in an inpatient setting. Part B covers the surgery if it takes place in an outpatient setting. The patient pays 20% of the Medicare-approved amount for the doctor’s services and the external breast prostheses. The Part B deductible applies.
Medicare reimburses for:
- Breast prosthesis: national law
- Panniculectomy
- Bariatric surgery
- Upper-eyelid surgery ([blepharoplasty] blocks vision) versus lower-eyelid lid surgery (considered cosmetic).
- Cleft lip repair: 15 states require this a reconstructive
Cleft Lip Repair: State law requires reimbursement in 15 states for cleft lip repair as reconstructive.
Liposuction as an adjunct to Abdominoplasty and Panniculetomy (Tummy Tuck):
Aetna Cosmetic Surgery Policy [CPB-0031]: liposuction when performed with a panniculectomy and also liposuction when performed with breast reconstruction after a mastectomy and not lipedema is considered reconstructive and not cosmetic. Update due 1-9-2020.