This document is an adjunct to the Liposuction for Lipedema Overview; a lot of the information is the same except it is formatted differently and the slant here is to specifically address misperceptions, vague terms, and how precise language and consistency are important to win appeals. Or goal is to gain widespread acceptance for Lymph-Sparing, Tumescent Liposuction (LS-TL) as a medically necessary treatment for Lipedema worldwide.
Q: Isn’t Lipedema the same as Obesity? No, it is a condition in which there is a pathological deposition of fatty tissue, usually below the waist, leading to progressive leg enlargement. Lipedema is often misdiagnosed as simply obesity or lymphedema. There is no cure for lipedema and it does not respond well to diet and exercise.
Q: Isn’t Liposuction a Cosmetic Procedure? I just read on a board-certified surgeon’s website that “liposuction is a cosmetic procedure and never reimbursed by medical insurance.” I would think they know more than you!
Answer: Not in regard to reimbursement. Performing a procedure has nothing to know with the dozens of issues regarding coding, documentation, carrier policies, and reimbursement. While a common belief, this is an inaccurate statement; most people simply think of liposuction as a cosmetic, body-contouring procedure. It is not in the Medicare fee schedule (no RVU’s) which means there is no generally-accepted reimbursement value for the four liposuction codes. Most doctors are not familiar with and do not confirm a lipedema diagnosis, and finally some surgeons either don’t know how or don’t want to file medical insurance for the procedure: they will earn less from medical carrier reimbursement.
Old Habits die Hard: Websites, doctors, associations, blogs and the general public general think of and refer to liposuction as an “aesthetic” and cosmetic procedure. However for a diagnosis of lipedema it is reconstructive. This has very important legal and reimbursement implications. See the question below on documentation on how to demonstrate it as reconstructive.
Q: I was told that all/most carriers won’t pay so why bother filing a claim? Three reasons: one is that some carriers (Anthem) have a payment policy, others have paid (estimates as high as 30% reimburse after multiple appeals), and last: if there is a class action suit against the carrier and it is won, you may be entitled to reimbursement even if your surgery was one or two years prior (depends on the exact wording of the settlement). If you never filed insurance you won’t be eligible. Also you may need to file at least one appeal (recommend at least two). Those who have won appeals typically win after the second attempt.
Q: What is Medical Necessity? This has connotations clinically and administratively. In terms of reimbursement any medical service or procedure must be supported by medical necessity (the conditions or disease, severity, and progression) to support the use and subsequent reimbursement for the procedure. A service may be medically warranted for the benefit of the patient (meets medical guidelines) but does not meet the carrier’s guidelines as being “medically necessary”. Therefore a service/procedure could be denied as not medically necessary because:
- Not FDA approved.
- The patient is too sick for the procedure (comorbidities) and the risk to the patient was not addressed.
- Experimental or Investigational (these are generally used interchangeably).
- Unproven is related to the reason terms above, but some carriers view it differently. For example, a procedure may be used widely and have decades of use, so it would no longer be considered experimental or investigational; the carrier simply doubts the efficacy and value of the procedure for treatment of a particular condition or disease).
Reconstructive surgery is approved if it is to “improve the function of a malformed body part.” [Medicare National Policy, MAR 2020]. Liposuction will be approved for lipedema if the insurance is convinced it is (1) medically necessary and not (3) investigational” or “experimental” or “unproven.” It must meet both hurdles. Some carriers (e.g., United Healthcare) consider “unproven” as different from the other two (others don’t).
Q: What is “investigational” or “experimental” or “unproven?”
Per Blue Cross and Blue Shield Association’s Medical Advisory Panel:
“A treatment is considered investigational or experimental when it has progressed to limited human application, but has not achieved recognition as being proven effective in clinical medicine.”
The Knox Keene Act (CA) has a rather strict view of what would be allowed regarding an “investigational” or “experimental” or “unproven” procedure:
“The patient has a life threatening or seriously debilitating disease which is expected to cause death within one year in the absence of effective treatment; the clinical trial has been approved by an Institutional Review Board (IRB) that will oversee the investigation;
United HealthCare Insurance Company uses an exclusion in its medical policies for treatments it considers “Experimental or Investigational.” The investigational definition merely requires that the treatment have approval from an appropriate regulatory body such as the FDA
Q: How should the documentation look?
It is imperative that Providers use verbiage that explains/reinforces that liposuction for lipedema is a reconstructive and that it:
- Restores the patient to a normal appearance. [emphasis on restore … to normal]. Use the term “malformed body part”.
- Improves function [ability to walk, mobility].
- Improve the patient’s quality of life.
- Based on evidence-based guidelines and research, liposuction is the only procedure available after all conservative treatments for lipedema have been exhausted.
It must also be documented and demonstrated to the medical insurance company the patient has completed conservative non-surgical treatment of lipedema without adequate relief of their lipedema symptoms. Also demonstrate that no comorbidities preclude the surgery.
Q: What verbiage should I avoid? Avoid using terms such as “contouring”, “improve appearance”, “aesthetic” or “cosmetic liposuction” in all Provider notes and pre-authorization letters.
I would avoid psychological benefits as most medical health insurance policies specifically state that “feeling better about yourself” is not a valid, medically necessary reason for a procedure. Most cosmetic procedures make “you better feel better”. It is best to avoid that comparison.
Be sure to include pictures and focus on function, mobility, progression of the disease, and the “deformity” of the condition.
Q: I was told there are no ICD-10 codes for lipedema. Is that accurate?
Currently (MAR 2020), There is no ICD-10-CM diagnosis code specific to Lipedema. After reviewing this problem, I’ve identified three ICD-10-CM codes used in the USA for lipedema. Each one has its problems.
R60.9 Edema [This is a Sign and Symptom code]
Q82.0 Familial Hereditary Edema [All “Q” codes are considered hereditary/congenital]
E88.2: Adiposis dolorosa; Lipomatosis dolorosa (Dercum’s disease) [An “E” code is an endocrine system code]
I would recommend R60.9 first and Q82.0 second. The E88.2 is related to the German ICD-10 codes but the “dolorosa” are distinctly separate conditions from lipedema. Note how each code is from a different section of ICD-10. Each one has drawbacks–the most important issue here is that we cannot specifically track lipedema as a unique condition. We urgently need a specific code for lipedema.
Q: I was told to submit the liposuction for lipedema procedure with CPT code 38999 (unlisted procedure, hemic or lymphatic system). Is that correct?
I do not recommend this. Using an unlisted code adds another level of complexity toward obtaining reimbursement. Unlisted codes are rarely reimbursed. It also reinforces the idea that the procedure is experimental and investigational–because there is no code for it! There are currently (2020) four liposuction CPT codes: (15876, 15877, 15878, and 15879).They have no Medicare RVU’s (there is no Medicare fee schedule for them). [More information is available in CPT Coding for Liposuction for Lipedema].