{"id":368,"date":"2020-09-28T10:52:32","date_gmt":"2020-09-28T10:52:32","guid":{"rendered":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/?p=368"},"modified":"2020-09-28T11:03:26","modified_gmt":"2020-09-28T11:03:26","slug":"frequently-asked-questions-faq","status":"publish","type":"post","link":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/frequently-asked-questions-faq\/","title":{"rendered":"Frequently Asked Questions (FAQ)"},"content":{"rendered":"\n

Q: Isn\u2019t Lipedema<\/strong> the same as Obesity?<\/strong> No, it is a condition in which there is a pathological deposition of fatty tissue, usually below the waist, leading to progressive leg enlargement. Lipedema is often misdiagnosed as simply obesity or lymphedema. There is no cure for lipedema<\/em> and it does not respond well to diet and exercise.<\/em><\/p>\n\n\n\n

Q: Isn\u2019t Liposuction a Cosmetic Procedure?<\/strong> I just read on a board-certified surgeon\u2019s website that \u201cliposuction is a cosmetic procedure and never<\/em> reimbursed by medical insurance.\u201d I would think they know more than you!<\/p>\n\n\n\n

Answer:<\/strong> That is absolutely not true. Many of those posts are many years old. Performing a procedure has nothing to know with the dozens of issues regarding coding, documentation, carrier policies and reimbursement. Most people simply think of liposuction as a cosmetic, body-contouring procedure. It is not <\/em>in the Medicare fee schedule (no RVU\u2019s) which means there is no generally-accepted reimbursement value for the four liposuction codes. Most doctors are not familiar with and do not confirm a lipedema diagnosis, and finally some surgeons either don\u2019t know how or <\/em>don\u2019t want to<\/em> file medical insurance for the procedure: they will earn less from medical carrier reimbursement.<\/p>\n\n\n\n

Old Habits die Hard:<\/strong> Websites, doctors, associations, blogs, and the general public general think of and refer to liposuction as an \u201caesthetic\u201d and cosmetic procedure. But, specifically for a diagnosis of lipedema, it is reconstructive<\/em>. This has very important legal and reimbursement implications.<\/p>\n\n\n\n

Q: I was told that all\/most carriers won\u2019t pay so why bother filing a claim?<\/strong> Three reasons: one is that some carriers (Anthem) have a payment policy [SEP 2020], others have paid, and as I mentioned in the Introduction<\/a>, you may be entitled to reimbursement as a result of a class action lawsuit against the carrier.<\/p>\n\n\n\n

Also you may need to file at least one appeal (I recommend at least two; Medicare has five levels of appeal.). Those who have won appeals typically win after the second attempt.<\/p>\n\n\n\n

Q: What is Medical Necessity?<\/strong> This has connotations clinically and administratively. In terms of reimbursement any medical service or procedure must be supported by medical necessity (the conditions or disease, severity, and progression) to support the use of the procedure (clinically) and subsequent reimbursement (administratively) for the procedure. A service may be medically <\/em>warranted for the benefit of the patient (meets medical guidelines) but does not meet a specific carrier\u2019s administrative <\/em>guidelines as being \u201cmedically necessary\u201d. That happens all too often. A service is denied as not medically necessary because:<\/p>\n\n\n\n

  1. It\u2019s not FDA approved (liposuction devices are FDA approved).<\/li>
  2. The patient is too sick for the procedure (comorbidities) and the risk to the patient was not addressed.<\/li>
  3. It is considered Experimental or Investigational (these are generally used interchangeably).<\/li>
  4. Unproven is related to the reason terms above, but some carriers view it differently. For example, a procedure may be used widely and have decades of use, so it would no longer be considered experimental or investigational; the carrier simply doubts the efficacy and value of the procedure for treatment of a particular condition or disease. They are challenging the research.<\/li><\/ol>\n\n\n\n

    Reconstructive surgery<\/strong> is approved if it is to \u201cimprove the function of a malformed body part.\u201d [Medicare National Policy, SEP 2020]. Liposuction will be approved for lipedema if the insurance is convinced it is (1) medically necessary and not (3) investigational\u201d<\/strong> or \u201cexperimental<\/strong>\u201d or \u201cunproven<\/strong>.\u201d It must meet both hurdles. Some carriers (e.g., United Healthcare) consider \u201cunproven\u201d as different from the other two (other carriers don\u2019t).<\/p>\n","protected":false},"excerpt":{"rendered":"

    Q: Isn\u2019t Lipedema the same as Obesity? No, it is a condition in which there is a pathological deposition of fatty tissue, usually below the waist, leading to progressive leg enlargement. Lipedema is often misdiagnosed as simply obesity or lymphedema. There is no cure for lipedema and it does not… Continue reading → <\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"nf_dc_page":"","om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[173,118,33],"tags":[35,14,36,28,159,167,111,5,99,102,119,6,15,24,16,23,22,26,27],"class_list":["post-368","post","type-post","status-publish","format-standard","hentry","category-documentation","category-education","category-reimbursement","tag-appealing-a-denied-claim","tag-claim-form","tag-cosmetic-surgery-policy","tag-cpt-code","tag-denial-reason","tag-diagnosis","tag-icd-10-codes","tag-lipedema","tag-lipedema-stage-1-stage-2-stage-3","tag-lipedema-stages","tag-lipolymphedema","tag-liposuction","tag-liposuction-reimbursed","tag-medical-insurance-companies","tag-medical-necessity","tag-medical-reimbursement","tag-reconstructive-surgery","tag-reimbursement-policy","tag-tumescent-liposuction"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/posts\/368","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/comments?post=368"}],"version-history":[{"count":1,"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/posts\/368\/revisions"}],"predecessor-version":[{"id":372,"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/posts\/368\/revisions\/372"}],"wp:attachment":[{"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/media?parent=368"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/categories?post=368"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/tags?post=368"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}