Requesting the Carrier Pay an Out-Of-Network Surgeon as In-Network

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What you must do:

  1. We are assuming that you’ve passed the approval hurdle, the surgery has been deemed to be reconstructive and medically necessary and not cosmetic. You have also discussed the number of procedures required (typically at least two, depending on severity).
  2. Often the insurance carrier will assign the nearest, board-certified plastic surgeon.
  3. Note that unlike cardiology or oncology, liposuction for lipedema is not a specialty. In fact, not every surgeon experienced in liposuction for lipedema is a board-certified, plastic surgeon. Many are primarily cosmetic surgeons and may be specialized in liposuction techniques. As a result, they may be a “cash-only” business and neither file claims or have a staff knowledgeable about reimbursement. They may be of very little assistance.
  4. Some are certified through other associations, such as the American Board of Cosmetic Surgeons (unfortunately we want to steer clear of that “cosmetic” term.) Some are not plastic surgeons. Technically, one need not be classified as a “surgeon” to perform liposuction. This is a distinction that the patient needs to be aware of. Many insurance companies and the American Society for Plastic Surgeons recommend that only a “board certified” plastic surgeon performs the surgery.
  5. Explain that liposuction for lipedema procedure is different than cosmetic liposuction.
  6. Explain that experience and training matters and the total number of procedures performed relating to lipedema is relevant.
  7. Now the issue is who will do the surgery and the issue is that you don’t believe anyone local, or in-network surgeon is qualified.
  8. If you are requesting both approval and an out-of-network exception note that the delay may be much longer (than three weeks, for example) and these are two separate issues.
  9. Read your carrier manual for instructions and definitions of getting an “out-of-network exception.” Some call it a “network gap exception.” They should provide instructions for the process.
  10. Remember that every insurance company is different, every case is different, and success may depend on the individual account representative. Don’t assume anything and document names, times and actions.
  11. Provide the out-of-network provider’s contact information.
  12. Provide a date range during which you expect to receive the requested service. For example, from Sept 1, 2020, to Dec 31, 2020. I would make the date no sooner than three weeks; some insurance will take three months to decide.
  13. Provide the names of any in-network providers of the same specialty within your geographic area along with an explanation as to why that particular in-network provider isn’t capable of performing the service.
  14. You could compare number of liposuction for lipedema procedures performed per year or lifetime as a benchmark.
  15. There are relatively few surgeons expert in liposuction for lipedema. Some estimate the number is fewer than 25 nationwide.
  16. There is no in-network provider capable of providing the service you need within a reasonable distance. Each health plan defines for itself what a reasonable distance is.
  17. You should ask for the network gap exception prior to getting the care.
  18. You may need to include the ICD-10-CM and CPT codes in your request. I have more on these in the Reimbursement Guidebook.
  19. The three most common ICD-10-CM codes used for lipedema, in order of usage, are: R60.9 Edema; Q82.0 Familial Hereditary Edema; and E88.2: Adiposis dolorosa; Lipomatosis dolorosa (Dercum’s disease). There is no exclusive lipedema code.
  20. For CPT™, the most common code is: 15879: Suction assisted lipectomy (SAL); lower extremity. 15876 is SAL for the head and neck; 15877 is SAL for the trunk, and 15878 is SAL for the upper extremities.
  21. The “Gotcha” on the codes above is that your argument is that the procedure is not SAL but more complicated; if the insurance agent makes an issue of this (you cannot use the code and then argue that it’s not accurate or appropriate) and you cannot get around it, then you would need to use an unlisted CPT™ code: 38999 (unlisted procedure, hemic or lymphatic system). This creates more problems but is not unsurmountable.
  22. If you have not met with your preferred surgeon then I would go with the R60.9 ICD-10-CM code and the 15879 for SAL for the lower extremities with the caveat that there are other codes that should be accepted.
  23. Talk to your surgeon if they have had success in getting out-of-network exceptions with a particular insurance company.
  24. If your request for an out-of-network is denied, don’t give up. Many states have laws requiring plans to cover such out-of-network services at in-network rates. First determine the reason and provide a rebuttal. If your request is still denied, federal or state law may require your insurer to allow you to start an “external” appeal.
  25. If the appeal process drags on, you may ask your surgeon if you could make an up-front payment but put the surgery out 3 months or more. An out-of-network surgeon may not be willing to spend additional time if they feel that you may decide to go in-network.

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This is a request for a network gap exception to cover liposuction for lipedema, a unique, reconstructive, medically necessary procedure from [Dr Smith] and out-of-network provider at the in-network rate.

All the evidence and guidelines support that not only is a modification of or derivation of suction lipectomy the most effective treatment to relieve symptoms of and ameliorate disability caused by lipedema-modified suction lipectomy is the only treatment of lipedema shown to halt its progression. The procedure goes by many names:

  1. Tumescent Liposuction
  2. Lymph-Sparing Liposuction
  3. Lymph-Sparing, Tumescent Liposuction
  4. Water-Assisted Liposuction (WAL)
  5. Power-Assisted Liposuction (PAL)
  6. It can simple be called reconstructive/medically necessary liposuction for lipedema (to differentiate it from cosmetic liposuction).[i]

One description of the liposuction for lipedema modification is Fibro-Lympho-Lipo-Aspiration (FLLA). The term is specifically referenced in the paper below (I have access to the full abstract if you’re interested):

Campisi CC, Ryan M, Boccardo F, Campisi C. Fibro-Lipo-Lymph-Aspiration With a Lymph Vessel Sparing Procedure to Treat Advanced Lymphedema After Multiple Lymphatic-Venous Anastomoses: The Complete Treatment Protocol. Ann Plast Surg. 2017;78(2):184-190. doi: 110.1097/SAP.0000000000000853.

NOTE: You can remove or reduce the references to FLLA in your submission. While technically correct, it will confuse most insurance account representatives. The inclusion here is to illustrate how different the procedure is from traditional, generic, cosmetic liposuction (SLA). This information is rather technical so only use what you are comfortable with or perhaps offer it as a template for your surgeon if he/she is open to the suggestion.

Everything about the surgical suction application via cannula is different from standard suction lipectomy. The goal is to relieve symptoms, ameliorate disability, improve function and halt disease progression.

The technique is vastly different from contouring, cosmetic liposuction. Only small blunt cannulas are used, great care is used to not injure lymphatic which are already abnormal and increased risk of injury.[ii] Only the longitudinal orientation of cannulas is used at critical junctures. Preoperatively critical lymphatic structures are scanned and marked. The surgery averages 4-5 hours, due to the removal of much larger aspirate volume than cosmetic suction lipectomy.

The benefit to lymphatics function comes not only from the removal of subcutaneous adipose tissue, but also the all components of the loose connective tissue including removing fibrosis in the interstitial space.

The term, suction lipectomy, suggests a technique whereby surgical insertion of cannulas into tissue attached to suction under tumescent anesthesia only removes subcutaneous fat for cosmetic improvements.

Fibro-Lympho-Lipo-Aspiration is directed at changing all components of the Loose Connective Tissue [ LCT]. For example, the application of suction-assisted cannulas has been shown to positively alter lymphatic function in patients with chronic lymphedema.[iii]

Lymphatic stasis results in dermal fibrosis, deposition of proteoglycans and fibrosis in the matrix, and excess adipose tissue accumulation.[iv] [v]

Suction lipectomy for lymphedema, or more specifically, Fibro-Lymph-Lipo-Aspiration, has been shown to decrease limb volume in extremities with chronic lymphedema after the restoration of lymphatic flow with lymph node transplant or lympho-veno anastomosis through the removal of solid adipose and fibrotic material that is a result of lymphatic stasis.

FLLA, as a modification of suction lipectomy results in a sustained volume reduction of the limb, sustained improvement in lymphatic function and reduced risk of cellulitis in both lipedema and lymphedema.[vi]

Again, the goal of this surgery is not removal of fat.

Fat may be an innocent bystander in the disease progression. The interstitial space, fibrosis and the subsequent development symptoms are the result of inflammation and increased extracellular fluid accumulation is what causes the symptoms and much of the disability.

Suction lipectomy and its CPT 15879 is a completely inadequate code.

The skill, work involved and time assigned to this code by payers is not adequate. It best describes a cosmetic procedure in person close to ideal body weight, who has a “small pocket” of cosmetically unappealing fat removed to improve their shape.

When payers value lipectomy codes they assume at most a liter or slightly more of fat removed in an hour or less.

For liposuction for lipedema, prior to surgery, surgeons assess lymphatic landmarks, including peri-saphenous lymphatic collection pathways to plan to execute the surgery without their disruption. A great deal of skill is required to not injure lymphatics. The surgery takes at least 4 hours and will often remove over 12 + Liters or 25 lbs of aspirate. This is not just fat removed, but also proteoglycans and other extracellular matrix components.

Data supports the improvements in lymphatic function and symptoms that result from my surgery. All the data from the phlebologist / venous and lymphatic specialist in Germany like Rapprich and Schmeller show improvements in QOL and lymphatic function surrogates like the need for compression and compression pump use. So again, it is much more that fat removal.

The free market valuation of lipedema surgery is from $7-$30K for the procedure.

[i] Peprah K, MacDougall D. Liposuction for the Treatment of Lipedema: A Review of Clinical Effectiveness and Guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; June 7, 2019.

[ii] Schaverien MV, Munnoch DA, Brorson H. Liposuction Treatment of Lymphedema. Semin Plast Surg. 2018;32(1):42-47. doi: 10.1055/s-0038-1635116. Epub 1632018 Apr 1635119.

[iii] Brorson H. Liposuction in arm lymphedema treatment. Scand J Surg. 2003;92(4):287-295.

[iv] Zampell JC, Aschen S, Weitman ES, et al. Regulation of adipogenesis by lymphatic fluid stasis: part I. Adipogenesis, fibrosis, and inflammation. Plast Reconstr Surg. 2012;129(4):825-834. doi: 810.1097/PRS.1090b1013e3182450b3182452d.

[v] Schneider M, Conway EM, Carmeliet P. Lymph makes you fat. Nat Genet. 2005;37(10):1023-1024.

[vi] Campisi CC, Ryan M, Boccardo F, Campisi C. Fibro-Lipo-Lymph-Aspiration With a Lymph Vessel Sparing Procedure to Treat Advanced Lymphedema After Multiple Lymphatic-Venous Anastomoses: The Complete Treatment Protocol. Ann Plast Surg. 2017;78(2):184-190. doi: 110.1097/SAP.0000000000000853.

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