Dr. McCluskey and his staff work very hard to help each patient gather their documents to form a strong argument for insurance approval. We believe that lipedema is a medical condition and that lipedema treatment via conservative or surgical means is medically necessary. The challenges of this are obvious. One of the primary surgical treatments for lipedema is liposuction. Insurance typically does not cover liposuction because insurance companies consider liposuction a cosmetic procedure.
We understand that this is very frustrating for patients suffering from lipedema but the vast majority of liposuction performed in the United States is for cosmetic purposes. Insurance companies cannot tell the difference between cosmetic liposuction and medically necessary lipedema liposuction. We have to work together with the patient to build a compelling case before the insurance company will consider reimbursement.
Critical pieces of this case include letters of medical necessity from multiple providers, gap exception letters, evidence of occupational therapy or physical therapy treatments, evidence of venous or lymphatic treatments, evidence of extensive work with a massage therapist or manual lymphatic draining specialist. Many of our patients are suffering pain swelling and edema and we work tirelessly to achieve insurance approval.
By sorting through this checklist and a more detailed checklist that we will provide for you, much of the paperwork can be completed before the initial consult. Various insurance providers and programs offer different levels of coverage which are out of our control. We have staff members who will have excellent relationships with insurance carriers and who understand how these systems work.
We have compiled a list of documents that need to be gathered and a stepwise process for submitting and seeking and gaining approval:
- It is best to have a PPO plan. While this is optimal in many cases there are PPO plans which exclude gap acceptance or single case exceptions. If you do not have a PPO plan we will have to start a prior authorization process and we will provide a letter of medical necessity.
- Here is a checklist of documents to gather. First we need to document that you’ve undergone conservative treatment which could include compression garments, Manual lymphatic drainage, exercise, and diet.
- We need documentation of all doctors visits related to lipedema, inflammatory and/or autoimmune disorders. We need documentation of any occupational therapy, physical therapy, exercise classes or chiropractic visits. We need a list of the names and contact information for all healthcare providers you have seen for this condition.4.
- You need two doctors letters confirming your diagnosis and saying why you need lipedema reduction surgery. We have the physicians available to provide both letters Dr. McCluskey will provide one and we have a physician who can provide another after evaluation.
- We need you to write your full story, your personal journey and beginning early in life with your struggles with lipedema and how it has changed with time.
- We need a consistent set of photographs of your body front back and both side angles from the feet up.
- We will provide a surgical plan including different stages of operations and then we will provide clinic notes consultation notes and operative reports afterward.