Your Insurance: Blue Cross Blue Shield Plans (except Anthem)

There are 32 separate state-based Blue Cross Blue Shield (BCBS) insurance companies in the United States. Although they are members of a single association, each company is independently managed and has their own policies. As a result, there is no single BCBS policy or approach to lipedema surgery coverage. Some plans cover with a policy. Some cover only in certain situations, and some will not cover without an external appeal.

Hundreds of our Members with BCBS have been Covered

We have helped hundreds of Coverlipedema.com members with BCBS plans get fully covered for liposuction, any needed skin excisions, and even panniculectomy or abdominoplasty for lipedema, even when not explicitly covered in the BCBS plan’s lipedema coverage policy.

Anthem Blue Cross Blue Shield, the largest BCBS insurer, issued a coverage policy for lipedema in the Spring of 2020.  Anthem is addressed in its own section and includes Empire BCBS, which is owned by Anthem.

The Nature of the Coverage Policies

We have worked with other BCBS plans to establish coverage policies. Our contacts at these plans are at the highest legal and clinical levels. The BCBS policies can vary greatly, but in most cases, we have helped several Coverlipedema.com members get covered under every BCBS plan and can help guide you to the same result.

A coverage policy prevents a BCBS plan from arguing that liposuction for lipedema is experimental or unproven. However, it does not make coverage easy. We believe that instead of issuing blanket denials, a BCBS clinical team will scrutinize individual requests and deny them based on perceived issues with diagnosis, conservative measures, and functional impairment.We recommend that you work with us from the beginning to minimize the chances of having to appeal a denial, which can be costly and time-consuming.

How We Help You with BCBS Insurance Plans

The Coverlipedema.com process walks members through all the documentation you need to gather, and we carefully review it to ensure nothing is missing or will cause scrutiny. We then add additional support to your package ensuring that the BCBS plan reviewer understands that you meet the diagnosis and other coverage requirements. This effort is necessary. Even years later, many BCBS plans have not trained their staff on lipedema, and some medical directors still believe that liposuction is a cosmetic treatment for the disease of lipedema.

We often help Coverlipedema.com members avoid denials by speaking with our BCBS plans contacts, some of whom we have worked with for over five years. Employer policies can also be a problem, so we help our members understand and navigate any potential prohibitions on liposuction and skin excisions imposed by their employers. We also help ensure the insurance company allows you enough time to complete your surgery plan.

Fair Payment can be Difficult with BCBS

Another problem is that BCBS plans have not updated the fee schedules used to pay plastic surgeons. Just because an insurer has a coverage policy, you cannot expect to pay upfront and submit a claim later. You must request pre-certification, and getting a coverage letter doesn’t guarantee you will be reimbursed fairly. We do not recommend paying an out-of-network surgeon for your surgery in full and submitting a claim later because insurers may only reimburse a small percentage of your surgery even if you have “out of network” coverage. We’re sure many of you have seen the stories where a woman who paid thousands of dollars for their surgery was only reimbursed hundreds. We recommend working with a plastic surgeon we have vetted and recommend for being truly insurance-friendly. That means they will not ask for a full cash payment upfront and will give you enough time to get a network exception required before getting a single case agreement.

Network Exceptions and Single-Case Agreements are Hard to Get

We must intervene in about a third of cases to ensure that a network exception is granted or the plan pays the surgeon fairly. Network exceptions and single-case agreements are unusual and are very hard for someone to get on their own, even with the help of a surgeon. Because we have been able to help hundreds of women get out-of-network care nationwide with many different plastic surgeons, we have access to data, arguments, and contacts at BCBS plans and state and federal regulators that make our efforts so successful.

Hope for the Future

On a policy level, Coverlipedema.com is advocating to the BCBS companies individually and to the BCBS National Association for a consistent coverage policy for all its members that fully respects the right to have safe, effective, and fully covered lipedema surgery.