One-Page Liposuction for Lipedema Reimbursement Checklist

After several months feedback has been to simplify, simply, and SIMPLIFY!

I’ve updated the checklist (Aug 14, 2020). I now have a one-page concise version plus a longer, three-page version.

The guidebook will be updated shortly in Aug 2020 and is now over 50 pages. While personally I think all the information is valuable and worth saving $15-$30K over self-pay, many have asked for a shortened version.

If you follow the checklist meticulously you should be able to obtain reimbursement from about 85% of insurance carriers. There will always be those 15% that will work extra hard to deny you. If you experience pushback or your pre-auth or claim is denied then you will need to read the guidebook and work the appeal process. Below are a PDF version and an Excel version of the Checklist.

The Tips document above includes additional tips based on some recent insurance submissions. If you have any suggestions for improvement or something that I missed please let me know. I am updating this document often. The data-sheet SS below is required information you will need for reimbursement. The earlier you get it the better.

Here is the short version below of the CHECKLIST:

1	LIPOSUCTION FOR LIPEDEMA REIMBURSEMENT: Determine with your managing Provider that all conservative measures have been exhausted and surgery is the next and only option. Asterisk * [right] means additional information is available.
2	Make a decision for surgery (in the future). [Website: www.lipoforlipedemareimbursement.com]
3	Review your insurance policy for coverage information.	*
4	Read your carrier manual for exclusions.	*
5	Check if there is a state or ins. Co. ombudsman or advocate. Medicare has one.	*
6	Should you pay for a reimbursement advocate? See question list.	*
7	Begin collecting Provider documentation 6 months or more in advance.
8	Obtain doctor letters and documentation. See below	*
9	Find a qualified surgeon familiar with liposuction for lipedema.	*
10	Many liposuction for lipedema experts are not contracted with insurance companies.
11	Many liposuction for lipedema experts are not not board-certified plastic surgeons.
12	Most surgeons require payment up-front before pre-authorization and approval. Confirm.
13	Most all approvals are case-by-case. Make your case the best.
14	Is the surgeon in network or out? (Most likely not contracted and out of network).	*
15	Plan may recommend an in-network board-certified plastic surgeon with no lipedema experience.
16	If your surgeon is out-of-network you may need to negotiate a Single Case Agreement (SCA).	*
17	Specifically request an “out-of-network” exception so they pay in-network fees.	*
18	There are no fee schedules for liposuction surgery (reimbursement can be any amount; case by case).	*
19	Establish number of treatments and that the ins. co. will reimburse.
20	The more info you send with the pre-auth the better.	*
21	The patient can provide a cover letter introduction and summary. Be concise and to the point!	*
22	Send Photos with pre-auth info. Determine how best to deliver them.
23	Expert Opinion Letters (EOL) need to support surgery as reconstructive and medically necessary.	*
24	Recommend doctors document stages.	*
25	Doctor must document progression and how liposuction will help.
26	Send documentation notes of at least six months of conservative treatment.
27	Provider letters should state that all conservative treatments have failed and the progression of the disease will worsen without surgical treatment.
28	If overweight address obesity management explicitly.
29	Include all relevant doctor progress notes and diagnostic tests.
30	Doctor must document that the patient has been compliant with all treatment.
31	Address comorbidities and any safety issues concerning treatment.
32	The treating physician must submit a Certification/Letter of Medical Necessity (LMN) form.
33	Get EOL letters from ALL your specialists!
34	Obtain Pre-Authorization. Need approval, amount, and number of sessions.	*
35	Get contact information from everyone you speak to! Ask for e-mails.
36	Some ins. Co. will send your claim to an External Review Board. This may increase the approval time.	*
37	If clinic does not file the claim you will need to submit the insurance claim.
38	If the ins. co. agrees to pay the clinic (per SCA), submit CMS-1500 form; patient pay is the CMS-1490 form.	*
39	Some ins. Co may approve in 3 weeks. Others may take months.
40	Doctor confirmed. Send Compression stocking care doco.
41	Doctor confirmed. Send Combined decongestive therapy (CDT) doco.
42	Doctor confirmed. Send Manual Lymphatic Drainage (MLD) doco.
43	Doctor confirmed. Send Lymphedema therapy doco.
44	Doctor notes: include pain measurements.
45	Doctor notes: surgery will improve functionality.	*
46	Doctor notes: surgery will improve mobility and gait.	*
47	Doctor notes: surgery will improve Quality of Life.	*
48	Doctor notes: “surgery will restore to a (more) normal appearance.”	*
49	Add to above: “of a malformed body part.”	*
50	Once all documentation is assembled, contact the ins. co. for pre-auth; expect 3-12 weeks. Case-by-case.
51	Send the ins. co. all requested information (and whatever additional you have).
52	If denied you can appeal multiple times and levels; Medicare has five official levels.	*