The Excel Spreadsheet of this list is the end of this document. Below is a Visio Graphic of the same information. I recommend both and the graphic alone could take an hour to review and understand.
This is a very important list. I recommend grading your documentation and case in regard to the issues raised below. Some like E/I/U you won’t be able to predict unless you the carrier has a specific policy that lists liposuction or liposuction for lipedema as E/I/U. Many are related to the quality, completeness and nature of your documentation. The better it is and the more you have the higher the chances of being approved. I would not worry about the denials that require a research review until you’ve been denied.
1 E/I/U Experimental/Investigational/Unproven
This is a research study battle. I have numerous papers that fight this argument. See How to use Research to Reverse Denials in the Guidebook. See my detailed review of ten E/I/U policies in the Reimbursement Guidebook Appendix.
2 Cosmetic This is strictly to improve appearance or aesthetics (avoid both terms!).
Some carrier representatives might state that the CPT codes are cosmetic. That is not accurate. What determines if they are cosmetic or reconstructive is the purpose and focus of the procedure–and the diagnosis it treats–in this case lipedema. Sell the four components of reconstructive surgery. Demonstrate that the ins. Co. is already paying for comparable procedures.
3 Conservative Measures Conservative measures are good enough; case not made that they are not effective.
Simply documenting six months of conservative therapy is not enough; list each measure, its duration, and effectiveness. It must be documented by the physicians that the conservative therapy results are not as expected and that without further intervention the disease will progress. If the notes indicate no status or that the treatments are effective that will hurt your case.
4 Lack Of Research Lack of research to support the efficacy and safety of liposuction.
Simply not true. There is plenty of research.
5 Patient is Obese Patient is obese and simply needs to lose weight; obesity is not addressed adequately. A carrier could deny the surgery and state that the patient simply needs to lose weight.
The documentation must clearly indicate, in the assessment and the plan that the patient is following a diet, typically KETO, and is compliant with it. Documenting a weight loss in the history is not sufficient. The patient could be losing weight due to the flu or any reason. No medical reviewer is going to go to the extra effort to calculate the weight loss from multiple visits. You are begging for denial and then would have to explain the situation upon appeal. Plus the surgeon should not be documenting this. The managing physician should. A reviewer could argue that there is no way for the surgeon, who was not there and did not manage the patient, would know if she was followed the regimen or the notes are accurate.
6 Patient Too Sick The patient is too sick for the operation (does not meet medical necessity).
The most common problems are cardiovascular, age, or weight. The argument is that the risk outweighs the benefits. Not that this is a separate medical necessity argument from the cosmetic versus reconstructive argument.
7 Patient Normal Weight Normal weight patients have a different set of issues. The photographs won’t be as dramatic in regard to a malformed appearance. The insurance company may be inclined to want to wait and see how the disease progresses.
This represents a challenge that the reviewing physician will determine liposuction is not necessary or it’s too soon. He/she may argue that the patient does not have a “malformed” appearance. You will need to use research to support your argument. Also focus on pain, functionality (ability to exercise) and the unnatural or misshapen appearance of the lipedema fat.
8 Expert Opinion Denial Expert opinion by xyz doctor said it’s not necessary Research the qualification so of the physician. Confirm experience with lipedema, specifically liposuction for lipedema, research papers and number of procedures performed. Lipedema does not fit into any specific specialty. Some experts are internal medicine, endocrinologists, or vascular surgeons. Dr. Iker, a specialist in lymphedema and lipedema, is a Physical Medicine and Rehabilitation Specialist.
9 Lipo Not Proven liposuction not proven to be effective or provide long-term benefit. not proven to reduce need for conservative therapy.
If you get an E/I/U denial be sure to get the specific reason. Read my write-up on E/I/U and then use research to illustrate that liposuction is effective, safe and proven to reduce the progression of the disease, improve functionality, restore to a normal appearance, and improve quality of life.
10 Study Size study sample size is small
Several studies have large sample populations. Avoid these and focus on the large sample size studies.
11 Lipo Not Proven Effective Liposuction Not Proven Effective
Numerous studies conclude that liposuction is effective. At worst they indicate the need for further research. The most common argument is lack of a control group (similar group that did not receive treatment).
12 Lipo Not Proven safe Liposuction Not Proven Safe
There are numerous studies indicating that liposuction, in general, is safe, and liposuction for lipedema is safe.
13 No Control Group There are two issues here. One is the issue of a “double-blind” test. It is virtually impossible with liposuction. There is no way to double-blind a procedure that changes appearance. It is an unreasonable request. The other, more reasonable is to compare the sample of liposuction patients with a comparator group that had no surgery. While a reasonable request, I am not aware of a specific study with a specific comparator group.
The expert reviewer could argue that the study should review 30 patients who have had liposuction and 30 who have not and compare the liposuction group to the control (non-surgical) group. This is a difficult one and you have to do your best with available research.
14 liposuction not proven liposuction not proven to halt progression
15 Early Stage Patient is in the early stages of lipedema and liposuction not necessary.
This may be related to the “normal weight” issues. Studies indicate that early intervention is recommended.
16 Expert Opinion Letter (aka Letter of Medical Necessity[LMN]). This explains the need for the liposuction surgery.
See the Checklist and Guidebook for details. Also I include a sample EOL template with specific verbiage and points the Provider should make.
17 Medical Clearance Letter The address that the patient is well enough to tolerate the procedure. I view this as different from the EOL or LMN above. If the claim is denied because the patient is too sick you need to address the co-morbidities and how you will address safety.
18 Co-Morbidities Co-morbidities were not addressed properly and based on medical necessity (the patient may die) the procedure is denied. This relates to the Letter of Medical Necessity documentation or Clearance for Surgery letter. The most important co-morbidities to address are vascular issues, morbid obesity, and the patient’s age.
19 Out Of Network No in-network surgeon is available. This is not typically an approval issue but how much they will pay for an out-of-network surgeon. Contractually they are supposed to provide coverage for your condition. Check on an out of network exception; per their contract they must provide coverage. It is the responsibility of the ins. Co. to have an in-network doctor.
20 General: Poor Documentation Documentation in general is substandard or inadequate or does not support the premise that liposuction is necessary.
As a medical auditor often I will find documentation that is repetitious, sparse and provides very little useful information. The note could be audited as correct, but overall is lacking in detail. Technically if the doctor does not sign the document, the medical reviewer does not have to accept it. If the physician documents compliance or treatment, it is considered fraud if the notes are not accurate. Anything added by the patient could be accurate or not–there is no way to know.