Three years ago, lipedema insurance surgery coverage in the United States was almost impossible. Now with some patience, knowledge, and assistance from Coverlipedema.com, everyone can get their surgeries fully covered in just a few months. Coverlipedema.com has helped almost 200 women get millions of dollars of lipedema surgery covered by their insurance plans.
Documentation can be costly
However, lipedema surgery coverage requires good documentation, which can cost money for consultations with doctors and therapists. These consultations can cost as much as five hundred dollars. Many of the surgeons and non-surgeon experts are out-of-network or only take cash payments. Some women have been reimbursed for visits to in-network experts, but we think that everyone should request reimbursement of the fees that they have paid to document their lipedema.
When You Should Request Reimbursement
If you are seeing a network surgeon, you can start submitting out-of-network expenses after you are approved for surgery. However, if you have an out-of-network surgeon, it’s best to wait until after your first surgery to pursue reimbursement since getting approved and the negotiation with your surgeon can be challenging and should be the focus. Usually, patients have six months to a year to submit claims for reimbursement. However, check your insurance plan to confirm your deadline.
How to Submit a Claim
To request a reimbursement, you will submit a member claim form to your insurance company. You can find that form on your insurer’s website. These forms are fairly easy to understand. Most of the information you will know, and your doctors or therapists can provide you with the rest. You will obtain codes to describe your visit from your doctors called CPT codes. Current Procedural Terminology (CPT) is a medical code set used to report medical, surgical, and diagnostic procedures and services. The CPT codes that are billed are typically CPT 99205 for a new patient visit and CPT 99215 for an established patient visit. These are high-level codes, and you should remind your doctor to specifically document that the consult with you lasted 60 minutes if you are a new patient or 45 minutes if you are an existing patient. Otherwise, there are lower-level codes that can be billed. You can also submit claims for telephone consultations but remind the physician to add the modifier -95 to the CPT code.
You should submit your claim form along with a bill from your doctor or therapist featuring correct codes and a description of services together with evidence that you paid the charge in full. You should also submit a letter stating that you have been covered for lipedema surgery and that your insurer’s network lacks physicians or therapists who diagnose and treat the condition. If you have a network exception, you can cite and provide that, too. You should also check your insurance plan because usually, you have a right to a reimbursed second opinion, even out-of-network.
If you are reimbursed a low amount for the consultations or therapy, you can use the website https://www.fairhealthconsumer.org to look up the CPT code for an out-of-network provider and argue for fair reimbursement.
Compression Garments can also be Reimbursed
Compression garments for post-surgery care can also be reimbursed in the same way using an insurance claim form. Just ask for a bill that references that you paid cash and includes the appropriate HCPCS code. These codes (pronounced “hick picks”) are a collection of standardized codes that represent medical procedures, supplies, products, and services.
In many cases with self-funded employer insurance plans, you can ask for the reimbursement of travel expenses (hotel, airfare, etc.) if you can show there was no closer network physician or therapist who is qualified to diagnose or treat you. If you have another type of insurance plan, it is still worth submitting a claim, but the possibility of success is not very high.
Don’t Give Up
Be tenacious with your insurer about paying timely and fairly. You should involve your employer or your state regulators if the insurance company seems to be ignoring you.
Historically, many women have been happy with getting $50,000 or more of surgery covered. Still, you should pursue the reimbursement of other expenses related to convincing your insurance company that you are deserving of surgery coverage.