Below is a sample letter to request a Reimbursement Policy Evaluation for Liposuction for Lipedema. While this example is Noridian Medicare, it can be used for any carrier. Just change the name and if they have any information in their manual I would add that as well.
There are a few approval policies, most notably the Anthem Blue Cross NC.0009 Cosmetic and Reconstructive Services Policy. Most insurance companies either consider liposuction cosmetic or do not reference it or lipedema. So you have your work cut out for you. The good news is everything you need to know is in this document. And if you need more help I can provide access to the full text of 150 research papers (Google Drive: email me) and the Reimbursement Guidebook.
Below is the Introduction ONLY.
To: Director of Medical Policy
Subject: Reimbursement Policy for Liposuction for Lipedema
Introduction
This is a request for a Medical Policy evaluation in regard to reimbursement for liposuction for lipedema, a reconstructive and medically necessary procedure that is the only remaining treatment once all conservative treatment measures have been exhausted. This document is to help you establish a formal policy.
Using the Anthem Blue Cross/Blue Shield policy as a template and supported with fifty medical research papers, the following is a formal, revised policy that will help patients suffering from this progressive and debilitating disease.
The procedure has many names, including:
Tumescent Liposuction
Tumescent Local Anesthesia (TLA)
Microcannular Tumescent Liposuction[i]
Lymph-Sparing Liposuction
Lymph-Sparing, Tumescent Liposuction[ii]
Water-Assisted Liposuction (WAL™)
Power-Assisted Liposuction (PAL™)
Laser-assisted Lipolysis (LAL)
Ultrasonic Liposuction (Vaser™)
In this document, to distinguish liposuction for lipedema from cosmetic liposuction, I will refer to the procedure as “lymph-sparing liposuction.” Providers may use any combination of the terms above including simply “liposuction.” This request will explain what lipedema is, recommended documentation requirements for liposuction reimbursement, and why lymph-sparing liposuction should be reimbursed.
I will make the case that lymph-sparing liposuction for lipedema is reconstructive, medically necessary and reimbursing this procedure would be advantageous to the patient and the insurance company. The procedure will slow the progression of lipedema, a progressive and debilitating condition, saving the insurance company thousands of dollars of care for a condition that has no cure and will only get worse without treatment.
The purpose of lymph-sparing liposuction is to:
- Restore to a normal appearance.
- Improve/restore function (mobility and gait).
- Address pain and bruising issues.
- Improve Quality Of Life (QOL).
These all meet the AMA™, American Society of Plastic Surgeons (ASPS), Medicare and Title XVIII Social Security Act requirements for a reconstructive surgical procedure. Per the Noridian Medicare Reconstructive LCD:
Reconstructive surgery is performed to restore bodily function or to correct a deformity resulting from disease, injury, trauma, birth defects, congenital anomalies, infections, burns or previous medical treatment, such as surgery or radiation therapy. Reconstructive surgery is reasonable and necessary when the purpose is to improve necessary functioning of a malformed body part whereas surgery addressing appearance alone is considered cosmetic and not covered.[iii]
Federal law, Section 1862(a)(1)(A) of Title XVIII of the Social Security Act reads:
Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services—
(10) where such expenses are for cosmetic surgery or are incurred in connection therewith, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member [emphasis mine];[iv]
This document will prove, based on a wealth of research, that lymph-sparing liposuction is not experimental, investigational, or unproven (E/I/U). There are dozens of positive, peer-reviewed research studies on liposuction for lipedema documenting that the procedure is safe and effective both short and long-term. [v]
Many Primary Care Physicians are unfamiliar with lipedema and misdiagnosis it. [vi] Many confuse it with edema, obesity, and lymphedema–all separate conditions. Due to the fact that there are few qualified surgeons for liposuction for lipedema, we also ask that you add an out-of-network waiver or exception.
Not all lipedema patients will be eligible for the surgery. As part of the pre-authorization package, it must be documented that conservative measures have been followed for at least six months, with limited results and that no other options are available to address the patient’s reduced functionality, lower quality of life, and pain. The patient must also be well enough for the procedure and all comorbidities–for instance heart problems–have been addressed. Research supports this:
“Implications of this new definition of liposuction [as reconstructive and medically necessary] should induce third-party public payers and insurance companies to reconsider their remuneration and reimbursement policies.”[vii]
Lymph-sparing liposuction meets and often exceeds the medical necessity requirements for other comparable procedures that are reimbursed such as breast reconstruction, cleft palate repair, and panniculectomy [tummy tuck] after bariatric surgery. Lipedema is a painful, disfiguring, and debilitating disease that impairs the patients’ ability to walk, exercise, and diminishes their quality of life. Without treatment it progresses into a malformed and disfiguring appearance that will impede the patient’s ability to even stand and walk. It meets not just one of the reconstructive criteria–it meets all of them. The procedures referenced above have all been historically denied as cosmetic at one time. Most are now reimbursed as reconstructive and medically necessary (some, like panniculectomy are reimbursed in the most egregious cases).
We are asking that you:
- Implement a positive reimbursement policy for liposuction for lipedema, a misunderstood and under-diagnosed condition.
- Differentiate between reconstructive liposuction for lipedema (lymph-sparing liposuction) and cosmetic liposuction in your policy manual.
- Designate lymph-sparing liposuction as reconstructive and medically necessary given that the patient’s documentation meets medically necessary requirements as outlined in this policy review request.
- Do not list liposuction singularly as cosmetic or liposuction for lipedema as an investigational or experimental or unproven procedure.
If you have any questions or need additional information you may reach me at [INSERT YOUR CONTACT INFORMATION HERE]
[This is the introduction above; download the entire 14 page document above]
[i] Jayashree V, Mysore V. Microcannular tumescent liposuction. Indian J Dermatol Venereol Leprol 2007;73:377-83
[ii] Tuğral, A., Bakar, Y. An approach to lipedema: a literature review of current knowledge of an underestimated health problem. Eur J Plast Surg 42, 549–558 (2019). https://doi.org/10.1007/s00238-019-01519-9
[iii] https://med.noridianmedicare.com/web/jfa/policies/coverage-articles/cosmetic-vs-reconstructive
[iv] http://www.socialsecurity.gov/OP_Home/ssact/title18/1862.htm
[v] Dadras M, Mallinger PJ, Corterier CC, Theodosiadi S, Ghods M. Liposuction in the Treatment of Lipedema: A Longitudinal Study. Arch Plast Surg. 2017;44(4):324-331. doi:10.5999/aps.2017.44.4.324
[vi] Wenczl E, Daróczy J. A lipoedema, egy alig ismert kórkép: diagnózis, társbetegségek, kezelés [Lipedema, a barely known disease: diagnosis, associated diseases and therapy]. Orv Hetil. 2008;149(45):2121-2127. doi:10.1556/OH.2008.28490
[vii] Atiyeh B, Costagliola M, Illouz YG, Dibo S, Zgheib E, Rampillon F. Functional and Therapeutic Indications of Liposuction: Personal Experience and Review of the Literature. Ann Plast Surg. 2015;75(2):231-245. doi:10.1097/SAP.0000000000000055