How to Hold Your ACA Health Insurance Accountable for Approving Liposuction Surgery

Your State Regulator Can Help You Get Fair Coverage

This information is only for those who’s insurance qualifies as a state mandated plan. Self-insurance plans (where your employer has designed their own insurance plan and provides this plan to their employees) are not regulated at the state level, they’re regulated at the federal level under ERISA. I’ll write more about that another time.

Let’s say you have submitted for your prior authorization for liposuction surgery and your insurance has denied it. You appeal, and again, your insurance denies your surgery. What do you do? Do you exhaust your appeals in a never-ending spiral of denials? Or is there another direction you can take to be more productive in getting approved for surgery?

What actions can you take against your surgery when you’ve been unfairly denied treatment?

If you're dissatisfied with the actions of your insurance company, you can file a complaint with your state Department of Insurance (DOI). Delays, denials, and unsatisfactory settlements are among some of the most common reasons for consumers to file complaints.

Jen’s Story

Jen felt like she’d finally turned a corner. After years of struggling with pain, swelling, and exhaustion from lipedema, a surgeon recommended liposuction surgery. It wasn’t just an option; it was the only way to stop the progression. She knew surgery wouldn’t magically solve everything, but it was her best chance at a healthier future. With her care team by her side, she gathered all the necessary documents and submitted the prior authorization.

But weeks later, the letter came: “Denied. Not medically necessary.”

That word—denied—hit hard. It wasn’t just the surgery being rejected; it felt like they were dismissing her experience and everything she had gone through.

Still, Jen wasn’t someone who gave up easily. She immediately submitted an appeal, hoping this time would be different. She wrote her own heartfelt letter, explaining how lipedema impacted her every day—how walking hurt, how compression garments were her constant companions, how no amount of dieting or exercise had ever helped. She pulled in letters from her doctor and therapist, hoping that this round would finally get the green light.

Another denial.

At that moment, Jen felt hopeless—like she was caught in a never-ending loop with the insurance company. She wondered if all her energy would just be wasted on appeals that would lead nowhere. The thought of giving up crossed her mind, but she knew she couldn’t let that happen. She deserved this care. There had to be another way to make them see that.

So instead of spiraling down with frustration, Jen got strategic. She began thinking outside the usual appeals process. After some late-night research and with the advice of an advocacy group, she found out that her individualized plan was regulated under the State Department of Insurance (DOI). She contacted her state’s DOI to review the denial, which would bring in an independent medical expert to evaluate her case. This gave her a sense of control—she was no longer at the mercy of the insurance company’s internal reviewers.

After months of waiting and countless follow-ups, her surgery was approved.

Jen’s story is a reminder that sometimes, getting the care you need isn’t just about fighting harder—it’s about fighting smarter. When the system tries to wear you down, you can find other ways forward. Whether it’s requesting external reviews, building a stronger case with specialists, or enlisting help from bureaucratic institutions, you don’t have to navigate it alone.

Just like Jen, you deserve this care. You are not a denial letter. You are someone with a life to live, and there are more paths to approval than the insurance company will ever tell you. It’s okay to step back, regroup, and take another approach. You’re not giving up—you’re just getting smarter about the fight.

If you want to learn more about your state’s insurance commission, I’ve put together a handy Google Doc with info on every State Department of Insurance in the U.S.:

A person can use their state Department of Insurance (DOI) to hold their insurance company accountable by following these steps:

1. Contact the State Insurance Department: Every state has a Department of Insurance (DOI) that helps people with insurance problems. You can call or visit their website to get information and support.

2. File a Complaint: If your insurance company denies coverage, delays payment, or you feel they aren’t treating you fairly, you can file a complaint with your state’s insurance regulator. This usually involves filling out a form online or through mail.

3. Provide Documentation: Make sure to send any relevant documents like denial letters, medical bills, and your insurance policy. The more information you provide, the easier it is for the regulator to understand the issue.

4. Wait for Investigation: After you file a complaint, the state regulator will investigate your issue. The DOI will review the complaint, contact the insurance company to request information about the situation, and analyze the company's response to determine if there was a violation of state insurance laws.

5. Resolution: The state insurance department may help resolve the issue by pushing the insurance company to pay claims, reverse denials, or explain their decisions more clearly.

Using your state regulator is one way to ensure that your insurance company follows the rules and provides fair coverage for your lipedema treatment.

I know this may seem pretty straightforward as it’s listed, but like anything insurance-like, the process is cumbersome and lengthy. I only say this because I want people to understand this is a marathon-fight to get the care you deserve. I encourage you to fight!

Take care,

Michelle