Does Your Insurance Cover Lipedema Surgery?
Here's a breakdown of what you need to do to qualify for surgery
I recently called my insurance company to get their benefit book to find out if they have any plan coverage for lipedema. I specifically wanted to find liposuction or any other surgical coverage. My insurance emailed me the book,
and I read through it with a fine tooth comb.
I wasn’t encouraged after reading all 108 pages. There is no specific language for Lipedema. To add insult, my insurance has 0% coverage for out-of-network providers. And there are no lipedema specialists in-network in my insurance plan.
However, there are many other plans with Medical Coverage Policies for Lipedema. Here are links to a few with hyperlinks to their plan coverage:
Blue Cross Blue Shield of Alabama
If you look through these plans, you’ll see similar qualifications with each plan:
Diagnosis of Lipedema from a physician and clinical proof of signs that you have lipedema, along with symptoms of pain, fatigue, etc.
Documented 3-6 consecutive months of conservative therapy (compression, healthy eating, physical therapy, manual lymph drainage, exercise, etc.) that has failed to relieve symptoms
Documentation of significant physical functional impairment (eg, difficulty ambulating or performing activities of daily living)-this is where the FCE (functional capacity exam) will show that you have restrictions on your mobility.
Photographs that show the affected extremities.
To get a preauthorization for liposuction surgery, you have to have these above criteria. Some plans will not have a written policy (such as my insurance). Even if your insurance doesn’t have a policy, you will still need these criteria at bare minimum.
If you are looking to have surgery, then follow this plan: get a proper diagnosis with a qualified physician who is familiar with Lipedema (I had to fly to another state to get a diagnosis) and make sure they do a thorough exam with photographs, perform at least three consecutive months of conservative therapy with a licensed physical therapist (I was lucky, there is a specialized lymphatic therapist in my town, but you may need to search for one), and after three months of conservative treatment, get evaluated by a physical therapist that specializes in a FCE or workers comp evaluation.
All of this will take some time and some money. There have been so many times I’ve wanted to give up because it can be so hard to work through this with all of the pain and fatigue, especially when there are no providers in my area to help. Here’s how:
Keep making phone calls. Start with finding a provider who can diagnose you with lipedema. That is the first step. Get diagnosed!
Call you insurance and ask for the medical policy coverage for surgical treatments for Lipedema.
If there is no coverage for Lipedema in your plan, use other plan policies as a general guideline. United Health Care is one of the strictest insurances for receiving coverage.
Make the effort to participate in at least 3 months of conservative therapy. My therapist has been my biggest resource for conservative care, and my biggest champion. She got me a lymph machine, and has provided all of the conservative care documentation I need for surgery, through her excellent clinical notes of our sessions together.
Shop for surgeons who are experts in lymph-sparing liposuction, and have experience with lipedema. There are only a handful of physicians who qualify in the United States (I can’t really speak for out-of-country providers) and even less who work with medical insurance. Find someone with who you are comfortable. You will likely need several surgeries and so you must feel comfortable with your surgeon. Most of these surgeons though are very accommodating to their patients.
Depending on the surgeon, you may have to submit your own preauthorization request, or you can work with their administrative staff. But, always be involved in your preauthorization request. This affects you and you alone, so make sure you have all of the documentation needed before sending it to your insurance.
Keep following me for surgery preauthorization and medical/surgical treatment for Lipedema, I’ll keep you informed of every step in my quest for managing my Lipedema and getting surgery.
Take care,
Michelle