Expert Opinion Template Sep 28 2020
“Liposuction is an effective treatment for lipedema and has a beneficial effect on net health outcomes based on clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature.”
Sample Medical Opinion Template
Hold Harmless Statement
This expert opinion for liposuction for lipedema reimbursement is provided for educational purposes only. It is not intended to represent the only, or necessarily the best, documentation or advice for the situations discussed, but rather represents an approach, view, statement, or opinion that may be helpful to persons responsible for writing an expert opinion letter in a medical clinic.
The statements made in this publication should not be construed as policy or procedure, nor as standards of care. Codes and policies change all the time; while every effort was made to ensure accuracy, the author makes no representations and/or warranties, express or implied, regarding the accuracy of the information contained in this book and disclaims any liability or responsibility for any consequences resulting from or otherwise related to any use of, or reliance on, this document.
- IMPORTANT: I am not a doctor and the information below was gathered from multiple sources.
- This cut-and-paste document is to be used by your Provider as a template; these are suggestions only. Only use what is medically accurate and documented in the medical record.
- If it is not documented, it did not happen; reporting a procedure or diagnosis that is not documented could be construed as fraud.
- My notes are [in brackets]. Global search and replace names [Mabel Moody] are also in brackets.
- The purpose of this template is to help your doctor think like a medical carrier reimbursement specialist–who is more interested in denying your claim as cosmetic, investigational, experimental or unproven. They may have never heard of lipedema or will immediately assume that liposuction is inherently a cosmetic procedure. That is not accurate. The may see the word “liposuction” and not read any further!
- Every word of your Expert Opinion Letter must demonstrate the procedure is reconstructive and medically necessary.
Jeffrey Restuccio, CPC, COC, MBA
Consultant
www.lipoforlipedemareimbursement.com
(901) 517-1705
Sample Expert Opinion Letter (EOL) for Liposuction for Lipedema
Note: some may also call this a Letter of Medical Necessity (LMN). It may also be included or part of a Clearance for Surgery letter but the focus of the clearance letter is to address pre-existing conditions, (co-morbidities) that may preclude the surgery. I would prefer that the Clearance letter be a separate document. The three most important safety issues to address are cardiovascular, obesity, and age.
DATE: September 28, 2020
From: [Dr. Adam Smith], Surgeon
RE: [Mabel Moody], D.O.B. 6-04-1970, SSN 123-45-6789
To Whom It May Concern:
My patient, Mabel Moody, has lipedema, [optional: stage 1/2/3*] that limits her functionality, mobility, and gait; decreases her Quality of Life (constant pain), and, as a result of the condition, has created a malformed appearance.[the phrase “malformed” is a specific term used by Medicare so use it – Jeff]
Lipedema is a progressive, adipose tissue disorder with no known cure. It does not respond to diet or exercise.
Photographs of her condition are attached.
She is limited in Activities of Daily Living and is unable to work or exercise on a sustained basis. This diagnosis has been confirmed through physical examination and medical history.
Stemmer’s sign is negative [if taken] and other indications represent lipedema versus lymphedema.
An ultrasound is included [if taken] and confirms the diagnosis of lipedema.
[Ms. Moody] was first diagnosed with lipedema on [July 31, 2010: INSERT DATE HERE].
[Ms. Moody]’s symptoms include:
Weight is gained disproportionately on hips, thighs and below knee (usually bilateral – affects both sides – and symmetrical – occurs evenly).
Larger bottom half and smaller waist.
The feeling of fatty ‘nodules’ underneath the skin.
Bruising occurs easily and is often unexplained.
Legs are very sensitive to the touch.
Deep throbbing/achy pain in legs.
Pain in knee joints
If possible include an over-all quantitative pain and severity score such as EQ-5D VAS (Visual analogue scale). [Molina, 2019 study]
Legs feel heavy and swell throughout the day (especially after long periods of standing or sitting) but resolve overnight.
Fat on legs is soft and looks dimpled like “orange peel skin“, legs may feel cold to the touch.
Lipedema fat does not respond to dieting.
Hands and feet are not affected.
Skin of affected areas may be pale and cold.
Upper arms may also be disproportionately fatter.
Increased swelling in hot weather.
General weakness.
Unstable walking or gait.
[Ms. Moody], as a result of her condition, has poor coordination.
In an 8-hour work day, [Ms. Moody] may [have the following symptoms / decrease in function/quality of life]:
[Ms. Moody] has undergone the following conservative treatments:
Manual Lymphatic Drainage (MLD); [list dates and outcome].
Combined decongestive therapy (CDT); [list dates and outcome].
Compression stocking care; [list dates and outcome].
[Ms. Moody] has been compliant with all treatments recommendations.
[Ms. Moody] has been compliant with a weight-loss program for her obesity as well as a [low-carbohydrate/Keto] diet regimen for both obesity and lipedema.
Her weight and BMI has decreased [xx percent], yet there has been little change in her malformed appearance, pain, functionality and quality of life. [This should also be documented in the managing physician’s progress notes].
I am enclosing all medical records, medical history, specific tests used, lab results, and relevant clinical findings.
A Functional Capacity Exam was performed on [insert date] and the results are:
An ultrasound was performed on [insert date] and the results are:
[Insert imaging test] was performed on [insert date] and the results are:
In my opinion, [Ms. Moody] is
Unable to resume any type of gainful employment due to physical impairment.
Her fatigue, pain, weakness, and other symptoms will significantly and consistently interfere with activities of daily living.
Without surgical intervention her condition will continue to worsen and potentially develop into lipolymphedema.
Lymph-sparing liposuction | tumescent liposuction | Water-Assisted liposuction [select one] is the only treatment, proven by research to be effective in improving function, reducing pain, and restoring the patient to a more normal appearance.
[Be sure to address in your letter (and all progress notes) these four key components:
- Restore to normal appearance
- Improve the patient’s functionality
- Improve the patient’s Quality of Life (QOL)
- The patient is well enough for the operation (Clearance for Surgery / address any and all co-morbidities)
GOTCHA! If you feel that I am repeating the four (4) components of reconstructive surgery a lot—I am. You, and your Provider, cannot repeat them enough. Why? Because it’s important to repeat and reinforce the notion that this surgery is not cosmetic and fits the official definition of reconstructive surgery. So, yes, I would like multiple Providers to include all four; I would like all cover letters and every conversation to include the list. If you contact the insurance company six times, you should repeat that the procedure is reconstructive, medically necessary and repeat that it meets the four components—every time.
Research shows lymph-sparing liposuction yields good long-term results in reduction of lipedema pain and in stopping the progression of lipedema (Liposuction-The Cure for Lipedema Fat) (Cornely et al., 2006; Schmeller et al., 2006; Warren et al., 2007; Rapprich et al., 2011, 2012).
[Clearance for Surgery Letter]
I have evaluated the patient for comorbidities and her suitability for the procedure and ruled-out significant risk for:
Cardio-vascular issues
Obesity.
Diabetes, hypertension and hyperlipidemia
Her age
[I am not an expert on pre-operative evaluations. The issue here is to document all comorbidities, if they exist, and how they will be addressed during surgery. Comorbidities and the danger to the patient’s health are a specific reason requests for pre-authorization are denied.
GOTCHA! The denial reason will be “medical necessity” but note that its safety and not the efficacy of the procedure that is the issue. The denial reason is the same but the issue and the appeal argument are different.
Without treatment my expectation is that [Ms. Moody] will see a continued decline in function and mobility over time, lasting longer than 12 months.
“Liposuction is an effective treatment for lipedema and has a beneficial effect on net health outcomes based on clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature.”
Request for Reimbursement Policy Evaluation for Liposuction for Lipedema is the most succinct list. It has fifty research references. Not all fifty reference liposuction but it’s’ a start.]
Sincerely,
[Dr. Adam Smith]
* There are three recognized lipedema stages (some research and numerous websites illustrate four; for more on this see our website: www.lipoforlipedemareimbursement.com).
Not one page but a word version of this you can share with your Providers.