In 2020 there are numerous medical carrier reimbursement policies that fall into the “maybe” category. The policy references either liposuction or lipedema but states that it may be evaluated as reconstructive and medically necessary. In that case you have to work the four components of reconstructive:
- Improve functionality
- Restore to normal appearance (never improve appearance)
- Improve or restore Quality of Life (QOL)
- The patient is healthy enough for the procedure (no comorbidities preclude the operation as unsafe).
Some policies, like Premera Blue Cross explicitly state that they consider the procedure as Investigational (aka Experimental/Investigational/Unproven). Reading their policy they gloss over the wealth of research related to liposuction and lipedema (no reference at all). This type of denial requires a research appeal and I have a list of 49 research papers plus reference 50 in the Policy Evaluation document. That’s a good start. Use the papers you like best. I also I can provide access to about 150 full papers on a Google Drive.
There are relatively few, explicit approval policies (Notable is Anthem Blue Shield).
Most insurance companies simply don’t reference liposuction or lipedema. Some reference liposuction only as cosmetic so that would require you to “educate” the carrier. Sometimes you have to educate your primary care doctor what lipedema is so it’s no wonder that carriers are unfamiliar with the diagnosis as well. Below are some Maybe policies.
The Medicare Policy also is vague indicating that cosmetic is not covered while reconstructive is. Medicare and the Social Security Act have very specific language of what construes reconstructive–and liposuction for lipedema restores one to a “normal appearance” or “restores a malformed body part to normal.”
https://www.medicare.gov/coverage/cosmetic-surgery
This is the Noridian Medicare Link. LCD Plastic Surgery L37020 Cosmetic vs Reconstructive Surgery: “reasonable and necessary” Suction assisted lipectomy to remove localized collections of unwanted fat in order to improve appearance is not covered. You must prove, with documentation and research, that the procedure is reconstructive (a maybe). Remember that there are 12 Jurisdictions so payment will depend on your specific Medicare carrier. There is no national policy. The local policies are known as Local Coverage Determinations or LCDS.
https://med.noridianmedicare.com/documents/10546/6990983/Plastic+Surgery+LCD
I’ve received reports that Tricare, the national insurance for the military, covers liposuction for lipedema. The policy states, “Liposuction when medically necessary” is reimbursed, so again, you have to prove your case.
Remember that the 50-plus Blue Cross/Blue Shield plans are mostly independent of one another. If they are owned by the same company they should have the same policy but there is no one, national policy for liposuction for lipedema. Blue Cross of North Dakota states: “The following procedures can be performed for either cosmetic or reconstructive purposes. If there are no procedure specific guidelines associated with a listed procedure below, the procedure may be classified as reconstructive only when there is documented functional impairment:
Suction assisted lipectomy done solely for cosmetic purposes.”
https://www.bcbsndmedicalpolicy.com/documents/cosmetic-surgery-vs-reconstructive-surgery/
If you follow my Checklist faithfully and have everything in order and the progression is clear and conservative measures are insufficient to stop the progression of the disease, the pain, impaired functionality, mobility, gain, and the patient presents with a “malformed appearance” it should be paid –every time.
Paramount Healthcare states that “liposuction included w panniculectomy (tummy tuck) or abdominoplasty” may be covered. Another maybe; another proof that it’s reconstructive.
https://www.paramounthealthcare.com/
Alabama Medicaid does not pay for cosmetic surgery or procedures. However, there may be coverage for eligible recipients if a procedure is found to be medically-necessary (reconstructive). These cases would require approval ahead of time (prior authorization).
https://medicaid.alabama.gov/content/10.0_Contact/default.aspx
There is clearly a pattern here. Always work on gathering documentation to support medical necessity in terms reconstructive versus cosmetic. The second main denial reason, Experimental, Investigational, and Unproven, is different and requires a different response. The different Denial Reasons are illustrated in my Graphic and my Top Reasons Spreadsheet.