When Will Kaiser Permanente Finally Recognize Lipedema and Cover Liposuction Surgery?
Kaiser is a real problem and we need to push back.
A lipedema patient once shared with me that Kaiser was great for general healthcare because it’s one of the more affordable plans. However, she added, “it sucks if you have an ‘exotic’ disease.” While lipedema is more common than most people know, our disease might be considered “exotic” because it’s not recognized in the medical community, with Medicare, or within many health plans.
Kaiser Insurance is the worst when it comes to denying lipedema surgery.
I’ve had women tell me how Kaiser providers gaslighted women, saying that Lipedema doesn’t exist, as they are pushed heavily into a weight loss cycle and set up for failure over and over. There is no medical policy for liposuction surgery, and as a closed HMO system, they do not have any Lipedema surgeons. Nor will they cover out-of-network surgeons (hence, the closed HMO).
In 2019, Gianelli and Morris, a Californian law firm, started a lawsuit against the Kaiser Foundation.
On May 16th, the California insurance law firm Gianelli & Morris filed a complaint in the Superior Court of Los Angeles County in the case of Elena Valencia, et al. v. Kaiser Foundation Health, Plan, Inc., Case No. 19STCV17131. The lawsuit alleges that Kaiser breached its contractual duties and acted in bad faith by refusing to provide coverage for surgical treatment of the plaintiff’s lipedema. The lawsuit seeks general, special and consequential damages as well as an award of attorney fees and costs and punitive (exemplary) damages.
This lawsuit started over five years ago, and in reviewing the court documents, it seems the case was dismissed in 2022. Today, we see that Kaiser still has no policies in place for lipedema reduction surgery, nor are they approving surgery.
Why is Kaiser denying liposuction surgery for lipedema?
Money is the driving factor for denying lipedema reduction surgery to their members. Here may be some reasons (which also apply to all insurances denying surgeries):
Classifying lipedema surgery as cosmetic for cost control: Labeling lipedema surgery as cosmetic helps Kaiser avoid the costs of surgeries. Kaiser offers liposuction surgery as a self-pay service through its cosmetic surgery program. Liposuction for lipedema is not cosmetic—it’s a medical procedure that involves surgical specialists and requires multiple surgeries, which makes it expensive.
Lack of Standardized Coverage Guidelines: Lipedema treatment isn’t uniformly recognized as medically necessary. Without an ICD-10 code and clear mandates, it’s easier for Kaiser (and other insurance companies) to deny care.
Opening the door to other claims: Approving liposuction surgery for one claimant can open the floodgates to other patients who also want surgery.
Prioritizing more cost-effective care: Kaiser may push for more low-cost conservative care (even though Kaiser has told many women that Lipedema doesn’t exist). They decide that conservative measures are enough to manage lipedema. If conservative care fails, they blame the patient for not following treatment.
If you have Kaiser insurance, what can you do?
A few months ago, I spoke with a woman who had been fighting Kaiser in the courts for six years. She was in a complicated and perpetual loop of court appeals, even though the court had ruled in her favor for liposuction surgery. Since then, she had not gotten anywhere with actually having this approval reinforced so that she could get surgery. Her attorney was at his wit’s end.
If you have a choice of insurance plans and don’t want to wait around for Kaiser to approve liposuction surgery, take advantage of open enrollment and sign up for a plan that is more well-known in supporting lipedema treatment.
If you don’t have the option to change your plan, you can go through the motions of preauthorization; however, expect to get denied. And then you might decide to go to some extreme lengths to get your surgeries.
Unfortunately, many women pay out-of-pocket for their surgeries. It’s similar to when breast cancer women had to pay for breast reconstruction before insurance was required to cover it.
I know women who’ve decided to take their retirement money and pay for their surgery because they can’t live their life anyway; they may as well spend the money on surgery to get healthy again.
I’ve talked to women who’ve done GoFundMe and other ways to raise money to get surgery. A few have been highly successful; many others have not.
I’ve also witnessed women who will fly to Europe to get surgery because the cost of the travel and surgeries are less expensive than getting surgeries here in the U.S.
I’ve seen women do extraordinary things when they need this surgery. I’m in awe of your resourcefulness in getting the care you need, no matter what.
I don’t have any great answers, but I believe in the power of community and the strength of our voices. Change won’t come to us—we must create a united movement to challenge the system. We do this by telling our stories, demanding care, and becoming the force of change that turns hope into action.
Take care,
Michelle
Yes, when I went to cleveland clinic the doc told me easier and less expensive to go to Germany. said Germany is top in the world for Lipedema. I wasn't up to going to Germany though.
It's the Kaiser plastic surgery dept that fights the existence of Lipedema. The first time I did an appeal with Kaiser for Lipedema surgeries I was approved (that was in Nov).
It is Kaiser’s policy that if they approve an appeal, for an out of network dr/procedure, the Chief of the dept who would normally do it (in our case the plastic surgery dept), is given the task to write the Outside Referral. It's the Chief of Plastic Surgery who sees any patient who has/thinks they have lipedema. The Chief of Staff of plastic surgery, vehemently insist lipedema is a made up internet disease.... You can't proceed with surgery until you get the outside referral.
When Kaiser's appeal reviewers, approved my surgeries, the rules in my EOC (Evidence of Coverage) says they have 7 days to write the Outside Referral. The Chief of Plastic Surgery refused to write the outside referral. The Appeals Dept employee said they couldn't force the dr when he would write it.
In March, after 118 days, the Kaiser Chief of Plastic Surgery, convinced the Appeals Dept to overturn my approval and issue me a denial.
The real problem is that the Chief of any Kaiser dept has a, Conflict of Interest, and should NOT be involved in writing the Outside Referral.
Each year, the Chiefs of the Depts are given a budget. (They think of it as their budget, but it is the budget for patient care)... In the event the dept is unable to treat a medically necessary condition, if the patient is treated out of network, the money for the patient's treatment comes out of the Chief's dept budget. At the end of each year the dept chiefs get a bonus based on how much money they have left in their budget.
Our multiple surgeries cost alot. My 5 surgeries were $125k. If they had to pay for all the lipedema women who are Kaiser patients, that Chief of Plastic Surgery is thinking, "There goes the boat." ... Kaiser’s method incentivises Chief's to deny patient care, otherwise they personally make less money.
I did go forward with an Outside Appeal, which I won. Kaiser had No Choice, they legally Had To Pay.