I encourage all doctors and associations to add, at the very least, the following single sentence to their website or blog (patients please share this with everyone who cares as well as your doctor; it can make the difference between reimbursement and a denial):
There are two kinds of liposuction: cosmetic* and “reconstructive, medically necessary liposuction for lipedema.”
For more information see HTTP://www.lipoforlipedemareimbursement.com
Better yet, include the following as well:
Key to reimbursement is confirming and documenting that liposuction is not experimental, investigative, or unproven but reconstructive and medically necessary (effective treatment supported by research). (And, yes, insurance companies, in over a dozen states, currently reimburse for reconstructive, medically necessary liposuction** for lipedema).
Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance (This is the AMA and ASPS definition; most insurance companies use a similar definition).
To be considered reconstructive a procedure must meet the following hurdles:
- Improve/restore to normal function (mobility, gait, and ability to walk).
- Restore to a normal appearance of “abnormal” or “malformed” body parts*** caused by the disease (lipedema). [Never to improve appearance.]
- Improve Quality Of Life (QOL). This would include pain
- Address any comorbidities (pre-existing conditions) that could cause a denial based on medical necessity due to the potential harm to the patient.
Additional notes to support medical necessity
In your pre-authorization packet of information be sure to include photographs! This is very important. They must illustrate the abnormal or malformed appearance and the decreased functionality, mobility, and gait.
I recommend not including the psychological benefits from the procedure. This is statutorily documented in numerous medical carrier policies as “not supporting medical necessity.” No matter how important you feel it is, focus on the four areas above and back up with research articles.
* For liposuction to be considered constructive, avoid using terms such as “contouring”, “improve appearance”, “aesthetic” or “cosmetic liposuction” in all Provider notes and pre-authorization letters. These terms all apply to cosmetic liposuction.
**You can also use the somewhat wordy, but accurate phrases: Lymph-Sparing, Tumescent Liposuction or Lymph-Sparing, Water-Assisted Liposuction (WAL). The only difference is that with tumescent liposuction the lidocaine (local anesthetic) and epinephrine (capillary constrictor) mixture is inserted into the subcutaneous fat first, then sucked out whereas with WAL the injection of the mixture is incorporated into the wand and performed simultaneously with the suction.
***Liposuction for lipedema is approved as medically necessary if it is to “improve the function of a malformed body part.” [Medicare National Policy, APR 2020].