How to get lipedema surgery covered by health insurance
Step by step for submitting pre-authorization and reimbursement claim to your health insurance provider in the United States
When I was diagnosed with lipedema, one of the first things my vascular doctor told me was that the only way to treat the disease effectively was liposuction, but he immediately cautioned me: “But insurance doesn’t cover it.” And he was right, most insurance companies and plans don’t cover the surgery because they still see it as either cosmetic or experimental.
However, a few insurance companies in the United States, mainly Anthem and Aetna, have been covering a few surgeries in the last year or so (2019/2020) in some states, so it’s definitely worth a shot.
In California, where I live, there was a class-action lawsuit against Anthem, which is not yet finalized but it’s lead Anthem to change their policy for lipedema surgeries.
Another thing that changed recently was that the WHO has finally recognized lipedema as a disease and created a code for it on the ICD-11. The U.S. is not yet using it, so the ICD-10 codes most used for lipedema are R60.0 and R60.9, which are generic codes for swelling.
The first step to getting insurance to cover the surgeries is to find out what are the criteria you need to hit. Your insurance should be able to provide you with this.
For Anthem, these are the criteria (you need to meet all of them):
- 1. There is a significant physical functional impairment (for example, difficulty ambulating or performing activities of daily living) or medical complication, such as recurrent cellulitis; and
- 2. When lipectomy or liposuction is reasonably expected to improve the physical functional impairment; and
- 3. Individual has not responded to at least 3 consecutive months of optimal medical management (for example, conservative treatment with compression garments and manual lymph drainage); and
- 4. The plan of care is to wear compression garments as instructed and continue conservative treatment postoperatively to maintain benefits.
This is how I personally submitted proof to Anthem that I met the criteria:
- 1. A letter I wrote detailing my health issues ever since I can remember them, the after-visit summary from the vascular doctor who diagnosed me (make sure they include a diagnosis code–insurance will need this), a podiatrist who stated my gait was compromised, the endocrinologist who’s treated me for 4+ years for Hashimoto’s and fatigue, plus an MRI that showed I had a cyst on my ankle and a torn ligament
- 2. Letter of referral to plastic surgery from the vascular doctor who diagnosed me, plus the proposed surgery plans from the plastic surgeons stating that surgery was expected to improve my condition and symptoms
- 3. Receipts for my MLD therapist and compression garments
- 4. After-visit summaries from the plastic surgeons I consulted with stating that I’d be wearing compression after the surgery and was instructed to continue with conservative therapies
Since most plastic surgeons don’t accept insurance, you’ll probably have to pay for the surgeries out of pocket and submit a claim for reimbursement after. However, most people miss an important step here, which is to file for pre-authorization BEFORE you have surgery. I did this 10 days before my surgery but would recommend you do it months before, ideally when you schedule your surgery. Give yourself some time to appeal in case they deny it.
To request pre-authorization, you’ll have to call the Utilization Review Department. I just called them and said I wanted to file for pre-authorization. They’ll ask a series of questions, including:
- Your insurance policy number and group number
- Proposed surgery date
- Diagnosis code
- Procedure code
- Information on both the doctor and surgery center: Name, address, phone number, fax number, license number, NPI number
Important: At this time, if you have a PPO plan, you should also request that your surgeon be considered in-network since there are no in-network surgeons that specialize in liposuction for lipedema. This will allow your claim to be paid at the higher in-network rate.
After this call, they’ll assign you a case number and will give you a fax number for you to submit evidence. That’s when the criteria above come into play. Fax all the documents you gathered that prove that you meet the criteria, and number every page so they don’t get lost. Also write your name, policy number, and case number on every page. Wait a couple of hours and call the Utilization Review Department again to confirm they received it, and make sure they confirm the number of pages received as well.
Useful tip: If you don’t have access to a fax machine, you can download apps that’ll allow you to fax things directly from your phone–they’re paid, but usually cheaper than going to Staples to use the fax machine, and more convenient as well.
Wait a few days or weeks and call them to check in on the case. If your surgery is coming up, they sometimes can mark the review as urgent.
After your insurance grants pre-approval, they’ll likely approve the claim reimbursement.
You’ll file the claim reimbursement once you have had the surgery. I did mine about 10 days after the surgery, once I was feeling better. You’ll need to download their claim form and fill it out–you should fill out one for the surgeon fees, one for the surgery center, and one for the anesthesiologist fees. This will speed up the process. The doctor’s office can help you with the right codes for each procedure, and they’ll also be able to provide you with an itemized receipt, which you’ll have to attach to the claim.
It took Anthem about 1 month to approve mine, and 2 weeks after that I received my checks. They covered 80% of mine, but I’ve heard of them only covering a few hundred dollars for some. However, I do believe it’s all about how you file, so make sure to follow the instructions above.
One caveat that I learned that you should be prepared for: insurance has up to 1 year to claim that they’ve made a mistake and ask you for a refund. So just be mindful that this could still happen even after they’ve paid you.
As always, I hope this article will help women in their lipedema journey. If you’ve stumbled on this and know someone who might have it, please share it with them. They’ll thank you.