Want to Know What Insurance Coverage for Surgical Treatment Looks Like?
Here's an Example of Benefit Plan Language for Coverage
I recently came across some insurance plan language (actually, I was searching for it), and I found a fantastic example through Cigna.
After a class-action lawsuit against Cigna, the insurance plan now has plan language specific to surgical treatment for Lipedema and Lymphedema. Many other plans, including UHC, Kaiser, and Blue Cross Blue Shield, have also had lawsuits filed against them. Many of the plaintiffs are winning their cases against these insurance plans. (That’s good news for us! Yay!! )
Here’s the link: Cigna’s Medical Coverage Policy for Surgical Treatment of Lipedema and Lymphedema.
Seriously, kudos to those of you who read the policy because plan language can be mind-numbingly boring and confusing.
But, I want to focus on the first two pages under “Coverage Policy” because these bullet points are the key indicators of the documentation you need to show insurance that qualifies you for surgery.
Below I’ve copied and pasted the verbiage and included some comments:
Most of these criteria can be met by physician assessment and documentation. This in itself can be a difficult undertaking because a physician will need to understand Lipedema and what to look for in an assessment.
There are two criteria that need assessments and treatment from physical therapy specialists.
Physical function impairment (i.e. difficulty ambulating or performing activities of daily living)
This criteria can be accomplished by an FCE, a Functional Capacity Evaluation. This test is typically used for worker’s comp cases, but it can also be used for illnesses. An FCE can help you demonstrate issues you have with sitting, standing, carrying, and bending.
Lack of response to at least three consecutive months of medical management (e.g. conservative treatment with compression garments and manual lymph drainage)
This criterion is consistent documentation by a medical professional(s), such as a physical therapy specialist in lymphatic drainage, which must be ordered by a physician.
I haven’t yet found another insurance carrier besides Cigna that has a spelled-out coverage policy. However, other insurance companies are covering surgery with the proper documentation.
Just because insurance companies don’t have criteria spelled out does NOT necessarily mean they will deny you coverage for surgery.
You have to look for the verbiage if it’s not spelled out, and it will be more difficult to get accepted, but it’s not impossible.
Since I have the type of insurance without a spelled-out coverage policy for Lipedema, getting accepted for surgery will make my journey challenging. I invite you to follow me further on this journey and learn more about how to do this.
Take care,
Michelle