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

There are 32 separate state-based Blue Cross Blue Shield (BCBS) plans in the United States. As each is independently managed, there is no single BCBS policy or approach to lipedema surgery coverage. Some plans cover with a policy. Others cover only in certain situations, and others will not cover without an external appeal.

Anthem Blue Cross Blue Shield, the largest BCBS insurer, started covering lipedema in the Spring of 2020.  Anthem is addressed in its own section and includes Empire BCBS, which is owned by Anthem.

The second-largest BCBS plan is Health Care Service Corporation (HCSC), which operates BCBS plans in Illinois, Texas, Montana, New Mexico, and Oklahoma. After many months of advocacy from Coverlipedema.com, they issued a coverage policy in the Fall of 2020. However, we believe they issued the policy more to avoid lawsuits than to actually cover the disease. They have the most requirements for coverage and, although we have helped a dozen women get covered for surgery, they drag their feet on coverage, network, and payment issues. At one point, they acknowledged the lack of qualified surgeons in Texas and agreed to work with us, but still recommend the same inadequate network surgeons for their members. They have resisted paying out-of-network surgeons a few thousand dollars when the in-network hospitals in Chicago make $10,000 or more a surgery when insurance covers. We are in regular communication with HCSC at the highest levels to address these problems, so please reach out to us for assistance in getting covered.

We also worked with BCBS of Michigan and Premera BCBS in Washington State to issue coverage policies. Both insurers are very reluctant to cover members seeing surgeons out-of-state, so some strategy is required as the in-state surgeons are either unqualified for or uninterested in lipedema surgery. We must engage the state or an employer at times to ensure approval of both the coverage and network requests on a timely basis. Premera also requires that conservative measures be done right before the coverage request.

Just because 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. Then, you only are responsible for your network coinsurance, co-pays, and deductibles.

Other BCBS plans, such as BCBS of Massachusetts, BCBS of Arizona, BCBS of Mississippi, Excellus, CareFirst, Horizon of NJ, and Highmark, have covered lipedema surgery at least once before. However, in our experience even insurers that have covered once, like BCBS of North Carolina and BCBS of Arkansas, can change their mind for new patients. Blue Shield of California will cover lipedema surgery, but only with in-network surgeons. If an insurer doesn’t have a lipedema coverage policy, we rely on meeting other insurer coverage standards and reaching out to them at the corporate level to ensure fair reviews.

There are other BCBS plans that have not reviewed a lipedema surgery request brought by us. So, we are very interested in expanding knowledge and coverage with BCBS plans in Wyoming, Hawaii, Idaho, Kansas, Rhode Island, Vermont, Tennessee, South Dakota, Nebraska, and Louisiana, in addition to Wellmark and  Capital Blue Cross Blue Shield. If you are covered any of these companies, please make an appointment to speak with us.

Blue Cross Blue Shield of Minnesota, Alabama, and South Carolina, as well as Florida Blue, Regence, Independence, still take the position that lipedema surgery is unproven and experimental. Given how many other insurers are covering, Coverlipedema.com has overturned their polices on multiple occasions. Although we win 95% of external reviews, there is some risk of getting a bad reviewer. We also can overturn “final” reviews and will appeal to the state or employer to get our members covered. This is a time-consuming and difficult process and can’t be done by yourself or by your surgeon’s office.

The Coverlipedema.com process walks you through all the documentation you need to gather, and we carefully review it to ensure there is nothing missing or that will cause scrutiny. We then add additional support to your package so the BCBS plan reviewer understands that you meet the diagnosis and other coverage requirements. Coverlipedema.com has good relationships with many BCBS plans, and although they drag their feet like other insurers on lipedema, we can resolve issues quickly. However, there have been issues with their prior authorization process, which we can address and often bypass when there are issues with processing coverage and out-of-network requests.

Regarding out-of-network surgeons, in states like California and Ohio, BCBS plans will likely refuse to enter into agreements with out-of-network surgeons because there is an in-network surgeon. Because of this, we do not recommend traveling to these states for surgery if you are not a resident. In other states, we are usually able to get members to the surgeon of their choice even if the surgeon is not in-network.  Additionally, we do not recommend traveling too far from your home state for the best chance of being covered to see an out-of-network surgeon.  Plans 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 that you live in are an important factors.

On a policy level, Coverlipedema.com is reaching out to the BCBS National Association and is advocating for a consistent coverage policy for all its members.