Wiki Tumescent, Lymph-Sparing Liposuction for Lipedema Reimbursement

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I would like to help with the many misconceptions concerning treating lipedema with tumescent, lymph-sparing liposuction [FEB 2020]. This is considered reconstructive surgery, medically necessary, and reimbursed by some (but not all) insurance carriers.

While strictly cosmetic liposuction (to improve appearance) is not reimbursed, reconstructive liposuction (for lipedema, removal of a lipoma, and in conjunction with a panniculectomy) is paid under very strict documentation and patient requirements and guidelines.

Lipedema is frequently misdiagnosed or wrongly diagnosed as lifestyle-induced obesity or lymphedema. It is estimated that as many 11% of women or 17 million have lipedema–and most are told they are simply obese.

Regarding liposuction and reimbursement please use the phrase, "reconstructive, tumescent lymph-sparing liposuction." For decades, both medical professionals and the general public have viewed liposuction as strictly a cosmetic, appearance-improving procedure. This has not been accurate for about twenty-years. I am aware that there different liposuction techniques (WAL, PAL, ultrasonic) but that is not relevant here.

To be considered reconstructive liposuction must be illustrated and documented to: Improve function or mobility (restriction of movement), restore to a normal appearance (not improve appearance), improve the Quality of Life (QOL) of the patient, and there are no comorbidities precluding treatment (i.e., vascular problems). Improving psychological well-being does not quality as reconstructive and should not be used.

To be reimbursed by a carrier the procedure must be considered NOT experimental and investigational, or unproven (in this case, for lipedema). Most carrier denials will use this objection and I have additional literature/research addressing this issue if you're interested.

There is no cure for Lipedema, it does not respond well to diet or exercise and not every lipedema patient is a candidate for surgery. There is no other option once all conservative measures have been exhausted.

The best strategy for reimbursement is to: Confirm if a board-certified plastic surgeon knowledgeable about tumescent, lymph-sparing liposuction is in-network with the patient’s carrier; and if not ask the carrier what will they pay out-of-network.

The Provider must document that he/she has optimized and exhausted conservative measures with at least six months documentation. The patient needs letters of medical necessity from all relevant physicians: primary care provider, surgeon, cardiologist, endocrinologist, orthopedic, etc... The patient needs to find their rights in their "Evidence of Coverage" health insurance contract. There it will explain whether liposuction for lipedema is covered and how to conduct an appeal. Get pre-certification for the recommended number of surgeries. Always expect to be denied at least once and that appeals are necessary.

Anthem Blue Cross CA reimburses for liposuction for lipedema: NC00009; Cosmetic and Reconstructive Services Published 11/12/2019.

Numerous board-certified plastic surgeons have filed medical insurance claims for lymph-sparing, tumescent liposuction and been reimbursed including: Dr David Gruener, NY, Marcia V. Byrd, M.D., GA, Gayle Gordillo, MD, IN, and Dr. David Amron, CA.

In a 2017 review of reimbursement for 27 advanced, disabled lipedema patients who underwent lymph-saving tumescent, liposuction, 6 were approved and 4 were paid after multiple appeals ([about 30%] source: Aug 2 2017 Fatdisorders.org presentation on reimbursement).

There are currently (FEB 2020) "Bad Faith / breach of contract" suits in California against about a half-dozen insurance companies on behalf of patients with lipedema who were denied coverage for reconstructive, tumescent, lymph-sparing liposuction. It is expected that most will change their policies as a result and reimburse based on the reconstructive surgery conditions listed above.

Many insurance companies simply have not yet addressed treating lipedema with reconstructive, tumescent lymph-sparing liposuction. It is not specifically referenced in their Cosmetic and Reconstructive Surgery Policy. This will change in 2020.

There are over forty, peer-reviewed journal articles reviewing the benefits, efficacy, and safety of tumescent, lymph-sparing liposuction as the only surgical treatment for lipedema. I can send you the list if you're interested. The latest, (FEB 2020) is very favorable toward tumescent lymph-sparing liposuction: Prevention of Progression of Lipedema With Liposuction Using Tumescent Local Anesthesia: Results of an International Consensus Conference.

https://www.ncbi.nlm.nih.gov/pubmed/31356433

I thank you for your time and consideration. Helping those afflicted with lipedema is for me both a job–and a passion. Please contact me if you would like additional information.

Jeffrey Restuccio, CPC, COC, MBA

ritecode@gmail.com

(901) 517-1705

ritecode

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I would like to help with the many misconceptions concerning treating lipedema with tumescent, lymph-sparing liposuction [FEB 2020]. This is considered reconstructive surgery, medically necessary, and reimbursed by some (but not all) insurance carriers. Most have to be appealed at least one time.

While strictly cosmetic liposuction (to improve appearance) is not reimbursed, reconstructive liposuction (for lipedema, removal of a lipoma, and in conjunction with a panniculectomy) is paid under very strict documentation and patient requirements and guidelines.

Lipedema is frequently misdiagnosed or wrongly diagnosed as lifestyle-induced obesity or lymphedema. It is estimated that as many 11% of women or 17 million have lipedema–and most are told they are simply obese.

Regarding liposuction and reimbursement please use the phrase, "reconstructive, tumescent lymph-sparing liposuction." For decades, both medical professionals and the general public have viewed liposuction as strictly a cosmetic, appearance-improving procedure. This has not been accurate for about twenty-years. I am aware that there different liposuction techniques (WAL, PAL, ultrasonic) but that is not relevant here.

To be considered reconstructive liposuction must be illustrated and documented to: Improve function or mobility (restriction of movement), restore to a normal appearance (not improve appearance), improve the Quality of Life (QOL) of the patient, and there are no comorbidities precluding treatment (i.e., vascular problems). Improving psychological well-being does not quality as reconstructive and should not be used.

To be reimbursed by a carrier the procedure must be considered NOT experimental and investigational, or unproven (in this case, for lipedema). Most carrier denials will use this objection and I have additional literature/research addressing this issue if you're interested.

There is no cure for Lipedema, it does not respond well to diet or exercise and not every lipedema patient is a candidate for surgery. There is no other option once all conservative measures have been exhausted.

The best strategy for reimbursement is to: Confirm if a board-certified plastic surgeon knowledgeable about tumescent, lymph-sparing liposuction is in-network with the patient’s carrier; and if not ask the carrier what will they pay out-of-network.

The Provider must document that he/she has optimized and exhausted conservative measures with at least six months documentation. The patient needs letters of medical necessity from all relevant physicians: primary care provider, surgeon, cardiologist, endocrinologist, orthopedic, etc... The patient needs to find their rights in their "Evidence of Coverage" health insurance contract. There it will explain whether liposuction for lipedema is covered and how to conduct an appeal. Get pre-certification for the recommended number of surgeries. Always expect to be denied at least once and that appeals are necessary.

Anthem Blue Cross CA reimburses for liposuction for lipedema: NC00009; Cosmetic and Reconstructive Services Published 11/12/2019.

Numerous board-certified plastic surgeons have filed medical insurance claims for lymph-sparing, tumescent liposuction and been reimbursed including: Dr David Gruener, NY, Marcia V. Byrd, M.D., GA, Gayle Gordillo, MD, IN, and Dr. David Amron, CA.

In a 2017 review of reimbursement for 27 advanced, disabled lipedema patients who underwent lymph-saving tumescent, liposuction, 6 were approved and 4 were paid after multiple appeals ([about 30%] source: Aug 2 2017 Fatdisorders.org presentation on reimbursement).

There are currently (FEB 2020) "Bad Faith / breach of contract" suits in California against about a half-dozen insurance companies on behalf of patients with lipedema who were denied coverage for reconstructive, tumescent, lymph-sparing liposuction. It is expected that most will change their policies as a result and reimburse based on the reconstructive surgery conditions listed above.

Many insurance companies simply have not yet addressed treating lipedema with reconstructive, tumescent lymph-sparing liposuction. It is not specifically referenced in their Cosmetic and Reconstructive Surgery Policy. This will change in 2020.

There are over forty, peer-reviewed journal articles reviewing the benefits, efficacy, and safety of tumescent, lymph-sparing liposuction as the only surgical treatment for lipedema. I can send you the list if you're interested. The latest, (FEB 2020) is very favorable toward tumescent lymph-sparing liposuction: Prevention of Progression of Lipedema With Liposuction Using Tumescent Local Anesthesia: Results of an International Consensus Conference.

https://www.ncbi.nlm.nih.gov/pubmed/31356433

Jeffrey Restuccio, CPC, COC, MBA

ritecode@gmail.com

(901) 517-1705
 

ritecode

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Messages
5
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I've set up a website to help anyone dealing with reimbursement for investigational, experimental procedures, and those ruled as not medically necessary and cosmetic. This includes liposuction for lipedema but also panniculectomies (tummy tucks), cleft palate, and other reconstructive procedures paid by some but not all providers.

The information is free. There is a Reimbursement Guidebook with both a 12-Step Reimbursement Strategy and a two-page documentation checklist.
 
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