We recommend that everyone starting the lipedema insurance process get a copy of their full copy of their insurance plan. If you have traditional Medicare, Tricare and some state Medicaid plans, there‘s no plan document. However, these plans do not specifically exclude liposuction for lipedema since it’s a disease and not cosmetic.
You can call human resources, look online or call the insurer to get a copy of your Plan. You are looking for the “Summary Plan Description” or “Benefits Book.” It’s usually over 50 pages and is not the same as the summary chart that everyone receives each year.
There are several sections of your Plan to check and even use in getting your surgery covered. If you download the Plan it’s easier to search.
- Checking to See if Your Plan Covers Lipedema: We have not yet seen a Plan specifically exclude lipedema. Sometimes liposuction will listed as excluded as cosmetic surgery. Lipedema is a disease so we easily argue it’s not cosmetic surgery. Note that we have seen a few United Healthcare self-funded employer plans with provisions that exclude all liposuction regardless of purpose. If your Plan has that provision, please contact us for a process to request that the employer allow your case to still go to an external reviewer. Liposuction is used for all kinds of non-cosmetic purposes and most employers just need to be educated about the disease and treatment.
- Does Your Plan Broadly Cover Reconstructive Surgery: Some Plans specifically state that reconstructive surgery is covered for breast cancer and others may also state it’s specifically covered for any disease, which would include lipedema. Because most insurers cover excisions, we ask for coverage anyway, but the fact the Plan has an explicit provisions can be helpful if the insurer denies coverage.
- What are the Network Limitations: Some Plans have limited networks with HMOs and EPOs being most limited. However, inherent in any medical insurance plan is that the network can provide the medically necessary services you need. So it’s always possible regardless of the limitations to ask for an exception to go out-of-network. Note if your Plan explicitly allows out-of-network services.
- What is the Time Limit for Filing Claims: If you are submitting claims after surgery this can range from 4 to 12 months. Sometimes the Plan also provides for how long it takes to pay claims.
- Payment for Out-of-Network Claims: Typically a Plan states payment for out-of-network claims is based on factors like Medicare rates, the insurer’s fee schedule, the payments in the geographic area or the surgeon’s cash charges. Note there is no Medicare rate for lipedema, and insurers might say they have fee schedule, but it often doesn’t reflect the complexity of lipedema surgery. Thus, you will be arguing for payment based on the surgeon’s cash rates and/or geographic area.