Your Insurance: Anthem Blue Cross Blue Shield
Anthem Blue Cross Blue Shield started covering lipedema in the Spring of 2020. Anthem operates the Blue Cross Blue Shield plans in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia, and Wisconsin. Anthem also owns Empire Blue Cross Blue Shield. Coverage includes liposuction and excisions, but not abdomoplasty, which we can get covered under other Anthem policies.
Once an insurer has a coverage policy, you cannot expect to pay upfront and submit a claim later. You need to request pre-certification, and getting a “coverage” letter doesn’t guarantee you will be paid fairly. We do not recommend paying an out-of-network surgeon for your surgery and submitting a claim later because insurers may only reimburse a small percentage of your surgery. It’s far better to work with a surgeon who will lower their rates and enter into an agreement with an insurer in advance, so they are treated like an in-network surgeon.
The coverage policy prevents Anthem from arguing that liposuction for lipedema is experimental or unproven. However, we expect that instead of issuing blanket denials, their clinical team will scrutinize individual requests and deny them based on the diagnosis, conservative measures, and functional impairment. We have been helping women with Anthem get covered for years and have the connections, data, and experience that quickly resolves these issues. We recommend that you work with us from the beginning to minimize the chance of having to appeal a denial which is more costly and time-consuming.
The Coverlipedema.com process guides you through gathering all the documentation you need to submit a strong coverage request. Then, we carefully review your documents to ensure nothing missing or will cause scrutiny. We also add additional documents so the Anthem reviewers understand that you meet their diagnosis and coverage requirements. Another issue with Anthem is they are so large in many states that knowing where to submit and follow up with them can be a problem, even when using an in-network surgeon. They have lost requests or sent them to the wrong department. We usually reach out on the member’s behalf beforehand to ensure the reviewers understand lipedema is covered and that the surgeon is either out-of-network or out-of-state.
We recommend that you work with us from the beginning to minimize the chances of having to appeal a denial which is more costly and time-consuming.
The Anthem policy doesn’t address finding a qualified surgeon. Anthem is a very problematic plan in this regard. Women in states like California and Ohio have been unable to see an out-of-network surgeon. Thus, we do not recommend traveling to these states for surgery. In other states, we are usually able to get members to the surgeon of their choice. For the best chances of being covered to use an out-of-network surgeon, we don’t recommend traveling too far from your home state. Insurers have been clear that, if you will travel for an out-of-network surgeon, you can travel for a in-network surgeon. However, your type of plan and state where you live are important factors.
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