At Total Lipedema Care we have been on the forefront of lipedema becoming recognized as a medical condition that requires surgical and medical treatment. Our physicians were an integral part of the team working on the United States Standard of Care Guidelines for Lipedema which has now been accepted and published. Because of this, insurers and medical providers are learning about the condition and treatments necessary to help people with lipedema.
A few years ago, it was almost impossible to get lipedema surgery covered by an insurance company and if it was covered, it could take months or longer. Over the past few years, we have increased recognition of lipedema on a national level and insurers are becoming more inclined to cover treatment costs in a shorter period. Total Lipedema Care is committed to continuously advocating for those who suffer terribly with lipedema.
As we have helped hundreds of women with lipedema surgery, Total Lipedema Care offers complimentary review and submission for coverage to your insurance company.
Below is important information to help you understand the insurance process which can be confusing and frustrating; we are here to help you.
Your insurance policy is between you and your insurance company. As much as we advocate for insurance coverage at Total Lipedema Care, we do not control insurance processes, how approvals are conducted, etc. Through our track record of successful surgical outcomes and our advocacy, we have developed good relationships with many insurers. Sometimes this can make the entire process less onerous and cumbersome, but not always.
You need to be your own advocate.
Lipedema surgical coverage is not an easy task. It will take a lot of effort on your part to be successful. This includes gathering all necessary information. It will also require you calling your insurance company for updates.
Overall Process of Submitting to Insurance:
- It is best to have a PPO plan.
- For any insurance policy other than a PPO, we will be happy to provide you with documentation to support your case, however you must start the prior authorization process. We cannot work with your carrier until you start the prior authorization process because their system is completely closed to outside providers. You will need to explain that other providers may not offer the type of care that is available at Total Lipedema Care and that you want us to treat your condition. At Total Lipedema Care we provide:
a. Years of expertise in the care of women with lipedema.
b. Contribution to the standards of care for lipedema.
c. Manual lipedema extraction (MLE) developed by Dr. Schwartz to gently remove lipedema tissue after removal of initial tissue using suction assisted lipectomy.
d. Recommendations for post-surgical aftercare that promote healing and the best outcome after lipedema reduction surgery.
e. Medical doctors to support people before after lipedema reduction surgery to get the best outcomes.
- To start the prior authorization process, call your insurance company to get their policies on Lipedema coverage, out-of-network benefits, deductibles, co-pays etc. We cannot do this for you.
- Collect all items on the checklist below. This is a general list of what most insurers ask for. Your insurer may require different or other documents. Please call them to find out all the documents they need from you.
- When you have gathered and completed all the information your insurer requires, we will review your packet and then submit for prior authorization. We are happy to review your insurance packet even if you are currently working with another group or organization.
- When the packet is submitted, we will typically get confirmation with a reference number. We will provide you with this number for use when you call your insurance company.
- Please follow up with your insurance provider regarding status. This could take days, weeks, or even months. We have no control over this and do not have any more information than you do at this point. Any correspondence we receive will be shared with you. Any information you find out, please let us know so we can better assist with the process.
- Our office will contact you once we have received an authorization approval for surgery and to discuss how to proceed.
- If your claim is denied:
a. We will do a first and second level appeal on your behalf.
b. If the 2nd level appeal is denied, you will have to request an external appeal. We will be happy to provide all your insurance records for that process.
c. At this point it is out of our hands.
- Personal Journey: Document your journey. Tell your story in full detail starting with the onset and how it’s affected your life. Include a description of pain in your lipedema tissue.
- Conservative Treatment: You need to demonstrate a history of conservative treatment for a period no less than three months which at a minimum includes compression garments, exercise, diet and manual therapy.
- Document Everything: Document your use of compression garments, physical therapy, manual lymphatic drainage, exercise classes, and any other therapy you may have tried. You will need receipts or any supporting documentation as proof that you have tried these therapies.
- Healthcare Providers: List the names and contact information of all the doctors and other healthcare providers you have seen for your condition and why.
- Letters of Medical Necessity: You will need two doctor’s letters confirming your diagnosis and stating why you need lipedema reduction surgery. Total Lipedema Care has physicians that specialize in diagnosis and treatment. We are happy to schedule you with one or more of our physicians to assist with this.
a. Dr. Schwartz will provide one letter of medical necessity.
b. Our medical doctors can provide the second letter you need.
- Pictures: Take clear pictures of your body, front, back, and both side angles.
- Surgical Plan: Total Lipedema Care will provide a surgical plan personalized for you.
- Clinic Notes: You will need our consultation/clinic visit notes and any other records from other medical professionals that will help support your case.
- FCE: You must have a functional capacity examination (FCE; also known as a functional assessment of disability). For your lipedema surgery to be covered by insurance, there must be a medical reason to do so. This reason can be the presence of swelling, pain or problems with mobility and other activities of daily living. A FCE can help you demonstrate issues you have with sitting, standing, carrying, bending, etc. Only trained Physical Therapists (PT) or Occupational Therapists (OT) can do this exam. Not all PTs or OTs have been trained, therefore you may need to call multiple offices.
Here is a list of companies that we know offer FCEs. There might be others. It’s best to check in your local area. If you find one, please let us know so we can add to our list to help others.
209-578-3290 Modesto, CA
209-667-4200 Turlock, CA
Impact Medical Inc.,
818-722-2142 ext 402
310-218-4300 Los Angeles, CA
At Total Lipedema Care, will do our best to get your procedure approved and obtain a single case agreement with your insurance company just for you. Please understand that we can never guarantee approval and that the insurance contract is between you and your carrier.
Please stay involved to help us help you.
We are so excited that you have chosen Total Lipedema Care!