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We are pleased to announce that Dr. Wright accepts patients for Lipedema Reduction Surgery in-network with United Healthcare.  We are delighted that United Healthcare is working with us to provide the lipedema patient community with in-network lipedema treatment options.  Please be aware that United Healthcare’s medical necessity criteria must be met to their satisfaction before approval.  This includes six months of conservative therapy (diet, exercise, compression), photo documentation showing disproportionate tissue of the extremities, and documentation of functional impairment. We also highly recommend that patients document their personal journey to share with their provider and UHC to prove their need for further treatment.

We aim to help the lipedema community obtain affordable in-network treatment and care.  We will continue to work with other payers to achieve fair compensation for the expertise and outstanding patient care and outcomes we provide to our patients.

Lipedema is a chronic condition affecting many women, causing disproportional fat distribution and significant physical discomfort. Fortunately, UnitedHealthcare (UHC) Insurance offers lipedema treatment insurance coverage, but it’s essential to understand their strict criteria and the steps required to get the coverage you need. We’re here to guide you through obtaining lipedema insurance coverage through UHC while shedding light on Dr. Wright’s success in securing coverage for his patients. 

United Healthcare’s Lipedema Coverage Policy

United Healthcare recognizes individuals’ challenges with lipedema and has developed a policy for treating this condition. However, it’s important to note that they have stringent criteria that must be met to qualify for lipedema covered by insurance. Below is the general outline of what criteria UHC is looking for. At the end of this article, we summarize the entire process that includes this criterion. 

Criteria for Lipedema Treatment Insurance Coverage

To be eligible for treatment for lipedema covered by insurance through UHC, you must meet the following criteria:

Diagnostic Criteria: You must meet all diagnostic criteria for lipedema. This includes having photographs showing disproportional fat distribution consistent with the diagnosis. Additionally, you must have documented evidence of the failure of disproportional fat to respond to medically supervised weight loss or bariatric surgery if your BMI is in class 2 or above (BMI +35).

Conservative Therapy: You should have completed medically supervised conservative therapy for lipedema for at least six months. This therapy includes compression garments, manual lymphatic drainage (MLD), and a low-carb diet. Documenting your efforts is crucial. You must document if symptoms persist despite diet adherence and compression use.

Medical Evaluation: In addition to diagnosing lipedema, you’ll need another diagnosis from your primary care physician (PCP) or a specialist who is not providing surgery for lipedema. This diagnosis should support the need for surgical intervention to treat lipedema.

Functional Impairment: To further substantiate your coverage case, you must provide documentation of functional impairment. This could include how lipedema affects mobility, physical activity, and daily life. Be sure to detail the limitations you experience due to lipedema, as this will strengthen your case.

lipedema treatment insurance coverage

Dr. Wright’s Success with UHC Coverage

One positive aspect to highlight is that Dr. Wright has had significant success in helping his patients secure lipedema insurance coverage treatment through United Healthcare. This speaks to the importance of having a knowledgeable and experienced medical professional on your side when navigating the insurance process. His patients have seen great success with lipedema surgeries and long-term quality-of-life changes. Below he and one of his patients were featured on FOX 2 St. Louis!

The Process of Obtaining Lipedema Insurance Coverage

Now that you understand the criteria for UHC’s lipedema coverage policy, let’s outline the steps to help you secure the coverage you need:

  1. Consultation with a Specialist: Seek a specialist who can diagnose and document your lipedema. This specialist should not be the one providing surgical treatment. Make sure to discuss your functional impairment during this consultation.
  2. Conservative Therapy: Undergo medically supervised conservative therapy for at least six months. Keep detailed records of your therapy sessions, progress, and any lack of improvement.
  3. Medical Documentation: Request a separate diagnosis from your primary care physician or another specialist supporting surgical intervention to treat lipedema. This diagnosis should complement the lipedema diagnosis.
  4. Photographs: Obtain photographs showing the disproportional fat distribution consistent with lipedema.
  5. Consultation with Dr. Wright: If possible, consider consulting with Dr. Wright or a similarly experienced specialist who can guide you through the insurance process. Their expertise can be invaluable.
  6. Submission of Documents: Submit all the necessary documentation to UnitedHealthcare, ensuring that you meet all the criteria outlined in their policy.  Include your personal notes and information about your journey in this submission. 
  7. Advocacy: Be prepared to advocate for yourself and your need for treatment. Insurance processes can be complex, but persistence can pay off.

United Healthcare does offer coverage for lipedema treatment, but they have strict criteria that must be met. By following the steps outlined in this article and enlisting the expertise of a knowledgeable specialist like Dr. Wright, you can increase your chances of obtaining the coverage you need to manage and treat your lipedema effectively. Remember that your health and well-being are worth the effort required to navigate the insurance process successfully.

Read more about the UHC Policy here.

We will make every effort to get patients approved for Lipedema Reduction Surgery; however, final approval for medical necessity and prior authorization is determined by United Healthcare and at the discretion of a Medical Director at United Healthcare.  We cannot guarantee patients will be approved for surgical procedures.

 Why Aren’t More Health Insurance Companies Covering Treatment for Lipedema?

The general rule of thumb for Lipedema Insurance Coverage claims reimbursements is that any given claim must be deemed “medically necessary”. Lymph Sparing Liposuction is nearly always considered a cosmetic surgical procedure in nature or experimental, meaning this is an elective procedure and not a medical necessity. Of course, as explained above, this is not the case for women with Lipedema, as lymph-sparing liposuction is the only treatment option for dealing with this disease that can reverse progression. However, the combination of the surgery being deemed cosmetic and election plus the general under-education and lack of awareness in the medical community has led to the battle patients and Lipedema surgeons are fighting. We must educate and advocate for these surgeries to be covered. 

Coding Lipedema Surgery with Cosmetic CPT Codes 15877-79 

The liposuction CPT codes 15877-79 are cosmetic codes that were never intended to be used by commercial insurers to cover reconstructive or medically necessary procedures to improve function and technically should not be used for reconstructive treatment. Because they are cosmetic codes and are not covered by Medicare, they have never had a value or RVU (Relative Value Units) assigned to them. Some medical insurers like Blue Cross Blue Shield exploit the lack of an assigned value for the codes they insist on using.  If an insurance company assigns little or no value to the surgery, even when it is a covered benefit, they can pay less for the 5-hour surgery than for a 15-minute follow-up office visit. This means that because they use cosmetic codes 15877-79, which can have little or no value assigned by commercial payers like Blue Cross Blue Shield, they can pay so little that they are, for practical purposes, technically “covering” treatment. But in practice, they’re not covering liposuction to treat lipedema. The good news, at least for now, is that UHC is covering Lipedema Surgery with a reasonable assigned value.

Contact a Specialist, Even If You Don’t Think Insurance Will Cover!

Despite the challenges and lack of coverage, some physicians, like Dr. Wright in St. Louis, do everything they can to work with patients to get insurance coverage. They are familiar with the ins and outs of different insurance providers, and their teams work extremely hard to get patient coverage. ERISA experts and attorneys can help you work on lipedema treatment coverage, and physicians can help you connect with them if you aren’t sure where to start. 

You might also come across individuals who are self-described as “patient advocates”. These individuals will present themselves as experts in getting coverage for you. Still, they’re not licensed individuals and are unlikely to be bound by patient privacy laws that you’ll get with physicians and attorneys. We are aware of players in this field who are bad actors and ultimately hurt the cases of patient coverage. Be sure to check the BBB listings, names, and addresses of anyone wanting to work with you, along with Google Reviews and website listings. 

Please reach out to our office, and Dr. Wright’s team would be happy to refer you to experts depending on where you are in your Lipedema diagnosis and treatment journey. We’re here to help, and happy to get you started!

 

When it comes to Lipedema Insurance Coverage and reimbursements, there truly is no black-and-white procedure or practice for getting the healthcare you need and deserve. It’s common for patients to assume their health insurance provider will fulfill their obligation to cover important claims, especially when dealing with vital or preventative healthcare treatments. But sadly, this reality becomes a nightmare for many women seeking life-changing treatment for their lifetime suffering from Lipedema. 

What is Lipedema? 

Lipedema is a subcutaneous fat disorder that primarily affects the extremities (legs, arms). Its progression is influenced by hormones, and it often affects lymphatic circulation. It was first identified in 1940 by Vascular Doctors Edgar Allen and Edgar Hines at the Mayo Clinic in Rochester, Minnesota. Unfortunately, awareness of the disease is more well known in Europe, and physicians and the general population in the United States are still widely unfamiliar with it, despite it affecting an estimated 10% of women across the globe. 

Today, awareness in the US is slowly increasing and a new appreciation of the importance of early diagnosis and treatment in the US is more widely recognized, which we continue to advocate for. Dr. Wright and other leaders in the diagnosis and treatment of Lipedema have worked diligently and unrelentingly to submit new ICD-10 CM codes to the National Center for Health Statistics (NCHS) to help aid healthcare professionals learn about and more easily recognize and diagnose patients with Lipedema, as well as to provide a specific code for health insurance providers to recognize in insurance claims for this disease. This code is a promising step forward in addressing the lack of awareness and understanding of Lipedema and the women who suffer from it, but there’s still work to be done. While the NCHS is expected to make its decision on the new codes at any time, there are still thousands of patients who find themselves in limbo.

Why does Lipedema require surgery?

Taking everything that we know and everything that’s still unclear, experts have broken down treatment into both surgical and non-surgical options. However, Lipedema is a progressive disease, and non-surgical options have proven to only slow progression rather than reverse it. Women suffering from Lipedema experience a wide range of painful side effects that impact their daily lives and often lead to more serious health concerns as progression continues. 

Examples of these side effects include the development of painful fat deposits on the inner, and upper thighs or arms, easy bruising and extremely sensitive skin that is tender to the touch, swollen and heavy limbs that make mobility difficult or impossible to move around at all, and any are no longer able to sit in chairs for more than an hour and lose the ability to climb stairs or even walk up steep paths. These side effects often lead to obesity, lymphedema, and they may develop more serious diseases such as diabetes, heart disease, high blood pressure, and/or high cholesterol. 

Both categories of treatment seek to improve the signs and symptoms of leg volume, pain, swelling, disproportionate limbs, and to prevent infection or further progression. However, because Lipedema is a progressive disorder, non-surgical options will only serve to try and eliminate further progression. Surgery via a specialized type of tumescent liposuction is the only way to remove lipedema fat that’s already developed – diet, exercise, and non-surgical treatment options have proved unsuccessful in removing this irregular fat.  Extra care must be taken during surgery to avoid lymphatic damage which may be more likely to occur in patients with lipedema. Yo-yo dieting and obesity have shown to make Lipedema worse – so finding the right treatment as early as possible is imperative. 

Treating Lipedema Changes Women Lives

Non-Surgical Treatment Options

To the dismay of patients, wearing medical-grade, tight compression garments 24-hours per day, seven days per week, is the key to improve circulation for the lymphatic system, making this a go-to prescription from Lipedema experts. Compression garments come in a variety of strengths and will be prescribed based on the stage and type of affected areas. The tighter the compression, the better. 

A healthy and consistent lifestyle of clean eating and low-impact exercise to address obesity will also help with Lipedema. A diet focused on low-carb and low-sugar has proven successful. Low-impact exercise such as walking, water aerobics, yoga, or gymnastics has also reported success. Patients must avoid yo-yo dieting while also permanently losing or, at the very least, maintaining their weight. What works for one patient may not work for another. Diet and exercise recommendations and healthy practices are essential, but ultimately should be based on the individual with the understanding that weight gain is not an option. 

Some patients opt-in to Manual Lymph Drainage massage (MLD), a gentle skin massage used to stimulate the circulation of the lymphatic system. While experts have yet to find significant evidence that MLD helps with Lipedema directly, some patients prefer it for its “hands-on” nature to addressing their symptoms. 

Click Here for More Non-Surgical At-Home Treatment Options!

Lymph-Sparing Liposuction for Lipedema

For patients in the later stages of Lipedema, the pain and disruption to daily life are not permanently addressed with compression garments, diet, and exercise alone. Traditional liposuction that uses general anesthesia, radio frequencies, ultrasound, or lasers are possibly damaging to the lymphatic vessels, and as such are not an option for Lipedema patients, either. However, Lymph-sparing liposuction is safe, using surgical techniques that avoid lymphatic injury, and the use of local tumescent anesthesia reduces the risk of complications. Generally, the most painful areas should be treated first, starting high on the legs and then moving downward in future surgeries. 

Lipedema is a disease that provides one challenge after another. First, it’s the challenge of getting diagnosed. Then, it’s the challenge of finding a treatment plan that will work. And most difficult of all, finding a treatment plan that your insurance provider will recognize as a covered procedure. As experts continue to emphasize, lymph-sparing tumescent liposuction has proven time and again to be the most effective treatment to slow the progression of lipedema. However, liposuction has historically been considered a cosmetic procedure in the eyes of health insurance providers.

Why Aren’t Health Insurance Companies Covering Treatment for Lipedema?

The general rule of thumb for Lipedema Insurance Coverage claims reimbursements is that any given claim must be deemed “medically necessary”. Lymph Sparing Liposuction is nearly always considered a cosmetic surgical procedure in nature or experimental, meaning this is an elective procedure and not a medical necessity. Of course, as explained above, this is absolutely not the case for women with Lipedema, as lymph sparing liposuction is the only treatment option for dealing with this disease that can reverse progression. However, the combination of the surgery being deemed cosmetic and election plus the general under-education and lack of awareness in the medical community has led to the battle patients and Lipedema surgeons are currently fighting. We must educate and advocate for these surgeries to be covered. 

When seeking treatment, women with lipedema are faced with two difficult decisions. First, they have the option to pay out-out-pocket for the necessary surgeries and hope for reimbursement later. For women without access to these types of funds, it’s not an option at all. Otherwise, they must decide to put off treatment until they can get their insurance provider to agree to cover the cost. More often than not, this process can take years, involves educating the insurance company themselves on the medical seriousness of the disease and necessity of treatment, and requires several levels of appeal. Some patients are lucky and find a partner and advocate in their healthcare provider, but even with a team behind them,  the journey is long and arduous. 

Can Anyone Help Women with Lipedema Fight for Insurance Coverage? 

Yes! Women with lipedema may have more resources available to them in this journey than they realize. Most importantly, it’s imperative that patients seek out doctors who are Lipedema experts – not just to ensure their surgeries and treatment plans are safe for their own health, but also to ensure their providers are familiar with the arduous journey of documentation during the diagnosis and treatment process. This will be key for getting claims covered – the devil is in the details when it comes to highlighting the medical necessity of these procedures and lipedema treatments. But in addition to their surgeons, there are both attorneys and health insurance claim advocates who can help you work to get your lipedema surgery covered. As a leader in Lipedema treatment, Dr. Wright can put you in contact with attorneys and advocates who also specialize in health insurance claim assistance for women with Lipedema. Attorneys do charge fees for their service but have an excellent track record. Advocates are often a free service for the patients, and many patients report extremely positive experiences working with them. The good news for women with Lipedema is that you may have more options than you realized – there are people here to help you fight, advocate, and get the health care coverage you deserve. 

What Do Health Insurance Attorneys or Lipedema Advocates Do?

Both attorneys and advocates can help you get comprehensive health care representation for your lipedema surgery. They can help you navigate health lipedema insurance claims, including complex policy analysis and the appeals process, assist or manage an independent external review of lipedema treatment is necessary, provide healthcare rights advocacy, and work through claim negotiations.

You also have the option to ask your insurance company if they have a patient advocate who can help insured patients get help with their medical problems.  Most larger employers have an HR or insurance company liaison that can work as your advocate for coverage for your lipedema. We always recommend starting this process here, in the hopes that your company or employer can set you up with an advocate from the very beginning. If not, local advocates who are familiar with your state’s medical insurer and their policies are also an option, which may be accessible through  Consumer Reports, a respected consumer non-profit organization.

If you experience a denial of a health benefit claim, you often have to make a choice between whether to forego treatment or figure out a way to cover the costs for the lipedema surgery on your own. These attorneys and advocates help you ensure your denials aren’t inconsistent with your coverage. If they are inconsistent, they’ll help you fight to get the coverage you deserve. Nobody should have to decide between a life-changing surgery for their health and emptying their savings accounts, and there are lipedema experts out there who can help you navigate your way through a complex system that seems designed to make it difficult, if not impossible, to obtain coverage or necessary treatment.

Please reach out to our office and Dr. Wright’s team would be happy to refer you to experts depending on where you are out in your Lipedema diagnosis and treatment journey. 

No matter how much research continues to support the proper diagnosis and identification of lipedema, there is still opposition in the medical community, including from insurance companies for lipedema insurance coverage. Lipedema is a very real and present condition that affects millions of individuals throughout the world every year. If you have been diagnosed with lipedema or face the challenge of finding a proper diagnosis, you’re no doubt concerned with receiving effective treatment and even how to pay for that treatment. A recent court win by UnitedHealthcare seems to have made this task even more difficult.

Lack of Lipedema Insurance Coverage

Lipedema is not a temporary issue but instead a lifelong condition that will impact your way of life. Treatments can end up being pricey if you do not have the proper medical coverage. Certain insurance companies continue to fight against coverage for certain treatments, stating they are not required or necessary. If you have lipedema, you know full well how necessary it is to reduce swelling and pain in your affected limbs. Some insurance companies may not even provide coverage at all by claiming it to be a pre-existing condition.

Recently, UnitedHealthcare Insurance Company was able to defeat a proposed class action lawsuit that claimed their coverage did not include proper lipedema treatment. This is a huge loss for the lipedema community. It is imperative that insurance companies utilize the available lipedema research and cover costs of the necessary treatments.

Difficulty with a Proper Diagnosis

Lipedema is a condition that many people, including some physicians, refuse to acknowledge. Physicians will claim that there is not enough research to support the identification of lipedema or that it is just obesity. Lipedema patients know this is not just obesity; the subcutaneous fat tissue associate with lipedema is nearly impossible to reduce with your standard diet and exercise. The medical community as a whole needs to understand this condition better, and Dr. Wright continually advocates for improved education regarding lipedema.

Trust the Professionals in the Field

Even with all the challenges presented by lipedema, there are those who you can trust. Dr. Wright continues to strive for better education, research, and coverage for the lipedema community. Do not let these challenges bring you down even further; let Dr. Wright and his expert team help you to reduce the symptoms of lipedema and live your life. Dr Wright can help find the right procedure to help manage your lipedema symptoms, such as lymphatic drainage massage. Don’t let lipedema take over your life; contact us today!