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Aetna – Clinical Policy Bulletin (CBD) Number 0031 Cosmetic Surgery

There has been some movement from a major health insurance provider, Aetna.    Policy number 0031, which addresses Aetna’s policy on cosmetic surgery was updated on March 29, 2019.  This updated policy does include a subheading for “Liposuction for Lipedema”. The policy summarizes the literature Aetna reviewed when updating the policy.  This literature included the standard of care clinical guidelines from Dutch and German lipedema experts. The policy also reviews studies showing the benefit of liposuction for Lipedema.

It is not entirely clear from the update what this means because in the same policy: Aetna’s CPB-003, they have listed the CPT Codes for liposuction surgery, CPT 15878-15879, suction-assisted lipectomy; upper and lower extremity, as “CPT Codes not covered for indications listed in the CBP” (pages 18 and 19 of the policy). This contradiction at a minimum makes it difficult to know for sure.

This means that although Aetna has recognized some of the research on lipedema and reviewed the clinical guidelines and recommendations, they still may not cover the liposuction procedure codes.  The policy does address CPT 15877 suction-assisted lipectomy; trunk as a covered code when certain selection criteria are met. However, the medical criteria the policy, states are for liposuction when performed with a panniculectomy and also liposuction when performed with breast reconstruction after a mastectomy and not lipedema.

Aetna has covered lymph sparing liposuction for patients with lipedema before and this policy update makes it more likely that they will cover it in the future but there always be restrictions. We work with medical insurance companies every day to get them to cover lymph sparing liposuction for our lipedema patients. All the patients who have received insurance coverage so far have demonstrated to the medical insurance company they have completed conservative non-surgical treatment of lipedema without adequate relief of their lipedema symptoms. Conservative measures that should be done prior to approval by insurance companies include: wearing compression garments, dietary interventions such adherence to a low carbohydrate diet [either ketogenic diet or the more balanced anti-inflammatory diet] and lymphedema therapy. These conservative treatments are not just a requirement for the insurers and all of the standards of care guidelines they are an important part of managing lipedema for the rest of the patient’s life. Building a persuasive case for insurance company coverage for surgery involves a multiple visit documenting the stepwise adherence to at least a couple levels of conservative management of the symptoms of lipedema. Often the insurer will also need additional information from their insured patients on how the lipedema disease is impacting their life and mobility.

There is some good news for patients with lipedema: Aetna major health insurance provider reviewed the information on the effectiveness of a specialized type of liposuction for lipedema when certain medical necessity criteria are met. The next review date for this policy is January 9, 2020. We are hopeful that we will have published US studies ready for review when Aetna reviews this policy again and have more good news to report.

We have included the link below to the full Aetna CPB-0031 for your review.

http://www.aetna.com/cpb/medical/data/1_99/0031.html?fbclid=IwAR2-ukyF9LYaK2roVnb1AGffl2Tx9UDjIFy5GmvQtgAKH-wfTjfcAa8NbGU