Appeals

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Appealing an Insurance Denial - Getting Started

Get ready for an insurance denial and appeal by doing the following immediately upon receipt of the denial:

• Create a master file where you will keep copies of all correspondence, appeal documents, and more; ideally this would be in cloud storage (Google Drive, One Drive, etc.) to prevent loss on a disc, harddrive, or home computer in the event of failure

• Create an excel spreadsheet (like the one below) that will keep track of dates/times you've called your insurance company, who you spoke with, what you spoke about, and any documents you sent/received so you can refer back to it

• Call your insurance company and:

  • • ask to be assigned a case manager, and get their name, email address, direct phone number/extension, fax number, and mailing address for correspondence

    • doublecheck the deadline for appealing the initial denial

    • request a deadline extension for the appeal if needed

    • ask the appeals coordinator's name and get their email address, direct phone number/extension, fax number, and mailing address for correspondence

• Find your state's department of insurance and file a complaint regarding the initial denial while your appeal is underway

• Draft your appeal

• CC your surgeon, your PCP, your insurance case manager, your insurance appeal coordinator, any outside advocacy agenc(ies) you're working with, and your state's department of insurance on all appeal documents so your insurance company knows many eyes are on the appeal

Appeal Cover Letter

• Use this example Appeal Cover Letter as a general template

• Color Key:

  • • Fill in your personal information where there are red text

    • Text in purple are suggestions; remove any irrelevant suggestions

    • Text in blue are examples; re-write or remove any irrelevant examples

• Include all of the procedures your doctor submitted for coverage in their initial request to the insurance company that was denied; use the same language as the billing codes the doctor submitted, for example liposuction would be "suction assisted lipectomy"

• As a general rule, I suggest requesting an expedited appeal on the grounds that Lipedema is progressive and causing disfunction so care should not be delayed; it may be denied for being expedited, but it's worth asking every time

• If your doctor has not already had a Peer-to-Peer review with the insurance company, request one during your first appeal

• If your doctor has already had a Peer-to-Peer review with the insurance company and your first appeal was still denied, request an Independent (External) review during your second appeal

Date: Month Day, Year

From: Your Name

Address

City, State + Zipcode

Phone Number

Email Address

To: Insurance Company

Appeals Department

ATTN: Appeals Coordinator Name

Insurance Company Address

City, State + Zipcode

Appeals Department/Coordinator Phone Number

Appeals Department Fax Number

Appeals Department/Coordinator Email Address

RE: Patient YOUR NAME member ID 000000000, appeal for PROCEDURE(S) NAMES [i.e. suction assisted lipectomy of lower extremity/upper extremity/trunk, panniculectomy, skin excision of leg/calf/thigh/abdomen/hip/buttock/lower arm/upper arm]

I received a letter from Insurance Company dated Month Day, Year denying coverage for the surgical treatment of my chronic, progressive, immobilizing, and painful disease, Lipedema. With this letter, I appeal the denial.

Your reasons for denial are that "[quote actual denial reason(s) given in denial letter]."

I appeal the denial on the grounds that my surgery is medically necessary and the accepted standard of care for the treatment of Lipedema, is not cosmetic in nature, will prevent further disability, and will improve my health by slowing or stopping the progression of the disease, preventing future comorbidities and early mortality, and improving my quality of life and my ability to perform the basic activities of daily living such as walking and self-care.

With this letter, I will provide proof that my Lipedema negatively impacts my health, causes great pain and limitation, and will lead to further disability in the future if not promptly and properly treated.

I have requested an expedited appeal so that my treatment will delayed as little as possible as my condition continues to deteriorate and cause pain and daily limitations. I am also requesting an Independent Review/Peer to Peer Review.

Sincerely,

Your Signature

Your Name

Appeal Table of Contents

• Use this example Table of Contents as a general template

• Color Key:

  • • Fill in your personal information where there are red text

    • Text in purple are suggestions; remove any irrelevant suggestions

    • Text in blue are examples; re-write or remove any irrelevant examples

• Put your name, insurance company name, insurance ID number, and type of request (1st appeal request, 2nd appeal request, etc.) at the top of every individual page

• Put "page # of ##" at the bottom of every page

• Put as many Medical Records in the appendix as needed - things like any doctor's notes mentioning lipedema or problems related to lipedema (lymphedema, chronic pain, joint problems, asthma, sleep apnea, skin problems, etc.)

• Include as much relevant research in the Research Appendix as possible

• Include any applicable reference materials in the Reference Appendix

YOUR NAME

INSURANCE COMPANY NAME ID #000000000

1ST APPEAL REQUEST

Table of Contents

I. Summary of Case

II. Characteristics of Lipedema

III. My Lipedema History

IV. Liposuction is Safe and the Only Effective Treatment for Lipedema

V. Liposuction is a Medically Necessary Treatment for My Lipedema to Improve My Pain and Mobility and Prevent Further Disability

VI. Insurance Company’s Reasons for Denying Coverage for Liposuction Are Not Valid and Are Not Supported by Medical Evidence

VII. Conclusion

Medical Records Appendix

• Medical Practice Name - Doctor's Name

Type of record (i.e. patient visit notes, diagnosis, letter of necessity, patient discharge notes, surgical consultation notes, etc.)

Research Appendix

• Title of research paper (author(s))

Reference Appendix

• Title of reference item (author(s) or name of publication/organization)

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Appeal Section I: Summary of Case

• Use this example Section as a general template

• Color Key:

  • • Fill in your personal information where there are red text

    • Text in purple are suggestions; remove any irrelevant suggestions

    • Text in blue are examples; re-write or remove any irrelevant examples

• Under 'Diagnosis,' start with the very first doctor you saw who diagnosed you with lipedema, and list any other doctors/surgeons/specialists you saw that confirmed your diagnosis of lipedema; mention any testing performed to confirm lipedema, where applicable

• Under 'Prior Treatment,' list any therapies you completed in an attempt to conservatively treat your lipedema; give each therapy a paragraph and include the prescribing/administering doctor's name, facility, city and state, type of treatment modality, time underwent that treatment modality, any improvements to your Lipedema because of that treatment modality, and how your Lipedema has not improved or has worsened post-treatment

• Under 'Recommended Treatment,' note if your doctor's request for a peer-to-peer was denied, or if one was completed but the procedure(s) were still denied

• Include if you're requesting a peer-to-peer or independent review as part of the appeal

YOUR NAME

INSURANCE COMPANY NAME ID #000000000

1ST APPEAL REQUEST

I. SUMMARY OF CASE

Diagnosis

In Month Year, Dr. Doctor Name at Practice Name in City State diagnosed me with stage I/II/III/IV Lipedema of the legs, hips, buttocks, lower abdomen, and arms. They confirmed my Lipedema through physical examination and testing(i.e. negative stemmer's sign, DEXA body fat scan, lymphoscintigraphy, lipectomy, etc.). Lipedema (also known as Lipoedema in Europe) is a chronically progressive, painful disease in which abnormal amounts of subcutaneous diseased adipose tissue deposits on the body. Dr. Doctor Name suggested rare adipose tissue disorder expert Dr. Karen Herbst's protocol, widely accepted as the standard of care by medical professionals for the treatment of Lipedema. This protocol includes treatment for venous conditions, compression stockings, lymphatic pump use, manual lymphatic drainage massage, diet and exercise modifications, supplements, and the surgical removal of all diseased adipose tissue by liposuction.

In Month Year I sought a second opinion, that of Doctor Name at Practice Name in City State. Dr. Doctor Name is a specialty (i.e. plastic surgeon, endocrinologist, etc.) that treats Lipedema. They confirmed I have Lipedema and the only effective treatment is liposuction.

Prior Treatment

***VEINS EXAMPLE*** I have successfully completed a series of vein treatments for chronic venous insufficiency/chronic venous hypertension/chronic venous reflux with Dr. Doctor Name at Practice Name in City State, including laser ablation/vein stripping/sclerotherapy. My Lipedema was unaffected by these vein treatments.

***MLD EXAMPLE*** I have successfully completed a ## sessions of manual lymphatic drainage, also known as decongestive therapy, with Name of Provider at Practice Name in City State. My Lipedema was unaffected by these treatments.

***AT HOME THERAPIES EXAMPLE*** In Month Year, Dr. Doctor Name prescribed a lymphatic pump/compression stockings/vibration plate/self MLD massage, which I have been using as prescribed. My Lipedema was unaffected by these conservative treatments.

***PAIN MANAGEMENT EXAMPLE*** I am currently in pain management with Dr. Doctor Name at Practice Name in City State, and have received treatment modalities (i.e. pain injections to joints, pain medications, joint stabilizing braces, surgically implanted devices, massage, acupuncture, physical therapy, etc.) for pain caused by the excess weight of my Lipedema. My pain persists as a result of my Lipedema.

***NUTRITIONIST EXAMPLE*** I have been seeing a nutritionist, Name of Nutritionist at Practice Name in City, State, since year. Despite nutrition counseling, adhering to a keto/paleo/carnivore/low carb/vegan/vegetarian/whole foods/whole 30/balanced diet, my BMI remains in the overweight/obese range and my Lipedema has not improved. Furthermore, I have been following rare adipose tissue disorders expert Dr. Karen Herbst's diet and exercise protocol since Year. I am currently taking the supplements she recommends as part of her protocol including list supplements. After x weeks/months/years on her diet and supplement protocol, my Lipedema has not improved.

***WEIGHT LOSS SURGERY EXAMPLE*** In Month Year I underwent weight loss surgery with Dr. Doctor Name at Practice Name in City State. I was able to lose ##lbs but my Lipedema was unaffected as evidenced by my inability to lose weight in my calves/thighs/legs/hips/buttocks/abdomen/arms.

***ORTHOPEDIC EXAMPLE*** I have been seeing an orthopedic doctor/surgeon, Dr. Doctor Name at Practice Name in City, State, since Year for knee/ankle/hip/shoulder/wrist/elbow pain. I have received treatment modalities (i.e. pain injections to joint, pain medications, joint stabilizing braces, surgeries, physical therapy, joint replacements, etc.) for pain caused by the excess weight of my Lipedema on my joints. My pain persists as a result of my Lipedema.

***PRIOR SURGERY*** In Month Year, Dr. Doctor Name at Practice Name in City State performed lymph-sparing suction assisted lipectomy with skin excision of my bilateral thighs. The pain, swelling, and bruising in my thighs improved greatly after this procedure, but the Lipedema in my calves/hips/abdomen/buttocks/arms was unaffected and my symptoms continue in those areas.

Recommended Treatment

In line with the accepted standard of care for Lipedema, Dr. Doctor Name recommended that I undergo lymph-sparing liposuction (suction assisted lipectomy, CPT code 15879) as an inpatient/outpatient procedure at Name of Facility/Hospital in City, State, which is in-network/out-of-network for Insurance Company. My diagnosing and treating physicians, including list doctor names, concur with this recommended surgery.

Dr. Doctor Name timely requested that my health insurance company, Insurance Company, authorize the recommended treatment of liposuction to treat my Lipedema. Insurance Company denied coverage for the treatment, claiming “[quote denial reason].”

***PEER TO PEER DENIED EXAMPLE*** Dr. Doctor Name also requested that my health insurance company, Insurance Company, complete a peer-to-peer review, but their request was denied.

***PEER TO PEER COMPLETED BUT APPROVAL STILL DENIED EXAMPLE*** Dr. Doctor Name also requested that my health insurance company, Insurance Company, complete a Peer-to-Peer Review, which was completed on Month Day, Year. Insurance Company still denied the procedure(s) requested after speaking with my doctor.

The purpose of this letter is to a request a Peer to Peer-to-Peer Review/Independent Review and reversal of Insurance Company’s decision to deny coverage of the recommended and necessary treatment of my Lipedema. As will be shown by the information contained herein this letter and my supporting medical documentation, the procedure for which I have requested coverage from Insurance Company meets the definition of “medically necessary” in my health plan contract, in that the surgery is necessary to reduce my pain, improve my daily functioning and mobility, and stop the progression of the disease and is therefore not cosmetic in nature. Liposuction is recognized by medical professionals and Lipedema experts worldwide as the only effective treatment to reduce the impairments caused by Lipedema, to improve function and mobility, and to prevent future disability. It is not a cosmetic procedure aiming to improve appearances.

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Appeal Section II: Characteristics of Lipedema

• Use this example Section II as a general template

• Color Key:

  • • Fill in your personal information where there are red text

    • Text in purple are suggestions; remove any irrelevant suggestions

    • Text in blue are examples; re-write or remove any irrelevant examples

YOUR NAME

INSURANCE COMPANY NAME ID #000000000

1ST APPEAL REQUEST

II. CHARACTERISTICS OF LIPEDEMA

Lipedema Presentation & Symptoms

Lipedema (or lipoedema, adiposis dolorosa, lipodystrophy, painful fat syndrome) presents as disproportionate adipocyte hypertrophy (or lipohypertrophy), by which abnormal subcutaneous adipose tissue compresses, disables and disfigures the lymphatic system. It is a chronic, progressive and painful disease where abnormal adipose tissue accumulates in the extremities, typically affecting more women than men and often has a genetic component. It was first named as a medical condition in 1940 by Allen & Hines at the Mayo Clinic. The adipose tissue accumulation is bilateral and symmetrical, sparing the feet and hands (absent Stemmer’s sign), is painful upon palpation, and does not respond to extreme weight loss modalities. A hallmark of earlier stages of Lipedema is the discrepancy in fatty tissue of the extremities compared to the trunk. This is in contrast to the fat associated with lifestyle-induced obesity, which is typically global and proportionate, affecting the hands and feet as well. Lipedema patients can present with nonpitting edema, interstitial thickening, decreased skin elasticity, noncancerous lipomas (or nodules, spheroids), angiopathies, neuropathies, hematomas, petechiae, and mental health issues. As Lipedema progresses, it can affect the trunk and lead to fibrosis of the tissues, metabolic syndrome, cellulitis infections, osteoarthritis and necessitated joint replacements, lipolymphedema, and elephantiasis, impeding mobility and increasing morbidity.

Lipedema Stage 1

In stage 1 Lipedema, thickened subcutaneous adipose tissue is present and resistant to diet and exercise efforts. Skin may appear smooth, but lipedemic nodules are palpable upon examination. Affected areas are tender to the touch, and unexplained bruising is seen. Lipedema is ideally treated at this stage before it progresses to mid-to-later stage Lipedema.

Lipedema Stage 2

In stage 2 Lipedema, the skin takes on an uneven texture with indentations and nodules (lipomas) visible. In addition to tenderness and bruising, pain and swelling are present at this stage. A person with stage 2 Lipedema begins to feel the daily impacts such as reduced stamina, pain limiting activities, and the psychological, social, and emotional effects of a disfigured appearance. Persons with stage 2 Lipedema may try to combat adipose tissue accumulation through restrictive diets and/or excessive exercise, potentially leading to eating disorders and/or body dysmorphia. Conservative treatments such as compression stockings and decongestive therapies may help ease some symptoms and potentially prevent progression, but Lipedema will remain.

Lipedema Stage 3

In stage 3 Lipedema, subcutaneous adipose tissue is disfiguring and projects outside of the skin, often folding over the knees and hindering mobility. There are large nodules visible that are painful to touch and cause deformity and gait abnormality. Swelling is consistently present, and there is a higher risk for developing lymphedema (lipolymphedema), metabolic syndrome, and fibrosclerosis. Stage 3 Lipedema is less responsive to conservative treatments. At stage 3, Lipedema severely impacts a person’s quality of life and is negatively affects their mobility and activities of daily living (ADL’s). It is critical to treat Lipedema at this stage before it can progress any further.

Lipedema Stage 4

In stage 4 Lipedema, large amounts of disfiguring subcutaneous adipose tissue projection makes daily life extremely difficult. Mobility is severely impacted, causing the need for a wheel chair or scooter to ambulate. Immobility leads to additional weight gain, fluid accumulation (lymphedema/lipolymphedema), fibrosclerosis, and metabolic syndrome. Disability and unemployment are likely. Self care is challenging, leading to recurrent rashes and infections such as cellulitis and likely necessitating the need for assistance with one's ADL's to avoid hospitalization. Conservative treatments are not effective for the daily complaints of Lipedema at this stage. Early mortality is likely if Lipedema is not promptly treated surgically.

Lipedema Progression

As Lipedema progresses, symptoms become more problematic for mobility and ADL’s and there is an increased risk of early mortality. The pain, limb heaviness, swelling, aching, and discomfort increase with each stage and make it difficult to perform daily tasks or exercise. It is not uncommon for those with later stage Lipedema to develop metabolic syndrome, which significantly increases the risk of early death by hypertension, diabetes, and heart failure. Neurologic and angiopathic complaints are not uncommon as the disease progresses, and the risk of developing lipolymphedema is higher in later stage Lipedema. Those with later stage Lipedema often have orthopedic complaints including foot, knee, hip, and back pain and osteoarthritis from excessive weight on the joints, and gait alterations impairing their mobility. In addition, those with long standing Lipedema often suffer from mental health issues such as eating disorders, body dysmorphia, depression, and social anxiety. Early diagnosis and treatment is necessary to prevent disfigurement and disability.

Lipedema is a Disease Recognized to Cause Disability and/or Death

“Lipoedema” was recently added to the World Health Organization’s International Classification of Diseases 11th Revision (ICD-11), which is the global standard for diagnostic health information and statistics. This inclusion means Lipedema has been recognized by the World Health Organization as a disease that not only has been observed in significant enough numbers in the world population, but it’s a disease that warrants further research as it negatively impacts human health and may result in disability or death. Lipedema also appears in the Online Mendelian Inheritance in Man (OMIM), a comprehensive collection of all known inheritable disorders.

Section II Research Appendix:

• • • An approach to lipedema (Tugral & Bakar)

Exploration of Patient Characteristics and Quality of Life in Patients with Lipoedema (Romeijn, de Rooij, Janssen & Martens)

• Lipedema: A Relatively Common Disease with Extremely Common Misconceptions (Buck & Herbst)

• Lipedema: A Review of the Literature (Okhovat & Alavi)

• Lipedema: An Inherited Condition (Child, Gordon, Sharpe, Brice, Ostergaard, Jeffery & Mortimer)

• Lipedema: an overview of its clinical manifestations, diagnosis and treatment of the disproportional fatty deposition syndrome (Forner-Cordero, Szolnoky, Forner-Cordero & Kemeny)

• Lipedema: An update (Wollina)

• Lipedema Fat and Signs and Symptoms of Illness, Increase with Advancing Stage (Herbst, Mirkovskaya, Bharhagava, Chava & Te)

• Lipedema, a frequently unrecognized problem (Fonder, Loveless & Lazarus)

• Lipedema, a Rare Disease (Shin, Sim, Jeong & Kim)

• Lipoedema: Anatomical Study, Diagnostics and Perioperative Environment (Sandhofer, Schauer, Sandhofer & Anderhuber)

• Lipoedema: from clinical presentation to therapy (Langendoen, Habbema, Nijsten & Neumann)

• Rare adipose disorders (RADs) masquerading as obesity (Herbst)

• S1 guidelines: Lipedema (Reich-Schupke, Schmeller, Brauer, Cornely, Faerber, Ludwig, Lulay, Miller, Rapprich, Richter, Schacht, Schrader, Stucker & Ure)

Section II Reference Appendix:

• Best Practices Guidelines: The management of lipoedema (2017 Wounds UK)

• Lipedema (Fat Disorders Research Society)

• Lipedema: The Disease They Call Fat (Dayan, Kim, Smith, Seo, Damstra, Schmeller, Frambach, Carmody & Foldi)

• Lipedema Foundation (brochure)

• Online Mendelian Inheritance in Man (McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine)

• International Classification of Diseases, 11^th Revision (World Health Organization)

• Liposuction Principles and Practice - Chapter 3: Lipedema and Lymphatic Edema (Shiffman Di Giuseppe)

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Appeal Section III: My Lipedema History

• Use this my example My Lipedema History as a general template

• Color Key:

  • • Fill in your personal information where there are red text

    • Text in purple are suggestions; remove any irrelevant suggestions

    • Text in blue are examples; re-write or remove any irrelevant examples

• This is where things need to get personal! Start from childhood and work your way through the years, highlighting all struggles both physical and emotional you've experienced due to your lipedema

• Under 'My Lipedema is an Inherited Condition,' talk about any potential familial links to lipedema, whether or not the person is alive and whether or not they were formally diagnosed with lipedema. Talk about any limiting conditions they had that were likely the result of having lipedema. For example, my mother developed and died from esophageal cancer from bulimia, the bulimia a direct result of her attempts to lose lipedema weight. She also took pain pills daily for joint pain from the excess weight of lipedema, suffered from chronic cellulitis infections, and developed lymphedema as the result of unresolved lipedema.

• Under 'My Lipedema Causes Me Pain & Decreases My Mobility,' talk about every way in which Lipedema impacts your life; include every symptom (see suggested problem list) you experience and what in prevents you from doing

YOUR NAME

INSURANCE COMPANY NAME ID #000000000

1ST APPEAL REQUEST

III. MY LIPEDEMA HISTORY

My Lipedema Pre-Diagnosis

CHILDHOOD EXAMPLE I was a very active child, typically spending my free time outdoors playing games and sports with friends. I loved to bike around the neighborhood, play backyard baseball with my dad, swim in our pool during the summers, and play tag, kickball, capture the flag, hopscotch, hula hoop and jump rope. Around age 3 I began dance classes and kept up with it for many years. Around age 6 I began gymnastics. In elementary school I discovered basketball and competed in fundraising tournaments, and I joined the bowling team and competed in televised events. In middle school I played soccer and volleyball, and was good enough to join an adult volleyball team at only 13 years old. I was often one of the first kids chosen during gym class to be on any team as I was gifted in nearly every sport I tried.

PUBERTY/TEENS EXAMPLE In high school things changed for me. Around the time I should’ve experienced my first menstruation, I began rapidly putting on weight. I began reducing my calories, increasing my activity level, taking diet pills, and I joined a gym in a desperate attempt to stop the weight gain. I continued to gain weight, especially in my legs, arms, hips, and buttocks, eventually reaching nearly 240lbs. Finding clothing to fit my unusual proportions became difficult, and I had to switch from my beloved jeans and t-shirts to skirts and dresses as nothing could accommodate my oversized arms, legs, hips and buttocks without being ridiculously oversized for my torso. I struggled with an eating disorder, including restricting calories to under 500 per day and exercising excessively, but no doctor would formally diagnose me with an eating disorder due to the size of my extremities as I appeared obese and in no danger of malnutrition. I began isolating myself, skipping high school classes, and not wanting to leave the house. I also began experiencing pain in my joints and didn’t get out of bed some days.

EARLY ADULTHOOD EXAMPLE After graduating high school, I was determined to lose weight and be healthier. I got a gym membership and went every day 6 to 7 days a week for 2 or more hours at a time. I paid for a personal trainer and began a combination cardio and weight training regimen that I followed religiously for over 2 years. Despite adhering to a vegetarian diet and exercising under the supervision of a trainer, my BMI remained in the obese range and my extremities did not see a reduction in size. I remained active, playing tennis in college and enjoying swimming, hiking, and biking with friends in addition to continuing my gym regimen. I continued to improve my diet by going vegan, focusing on organic whole foods, and eventually going gluten-free in an attempt to reduce my weight, but I remained in the obese category. Around age 22, the pain in my joints began to take a toll on my ability to remain active. My knees, hips, feet and back ached constantly, my flesh was painfully sensitive, and the movement of the abnormal fat on my arms and legs during physical activity made me unstable and sore. I eventually stopped going to the gym and ceased every sport and active leisure activity I enjoyed as I was just no longer able to participate due to pain. I graduated college but due to my chronic symptoms I never was able to transition into a career. I have now been unemployed due to disability since 2009.

SOCIAL EXPERIENCES EXAMPLE From my teens onward, I faced a lot of discrimination and critical remarks from my family, friends, employers, doctors, and strangers. I was told I must be eating poorly, that I probably wasn’t working out enough, that I had to be lying about my calorie intake and exercise frequency, that I can’t possibly be vegan because I’m overweight, that I must be lazy or unmotivated, that I’m unhealthy, and the list goes on. This includes Insurance Company’s denial letter indicating that I’m obese as part of their denial of this treatment. We live in a culture where being overweight or obese is solely linked to one’s lifestyle choices and comes with negative judgements and a lack of understanding. This reality is a very difficult thing to accept as a Lipedema sufferer, who appears as just another “fat” individual to the outside world. I cannot change my reality without the recommended treatment as I suffer from a medical condition, not lack of willpower.

My Lipedema is an Inherited Condition

Through my discussions with Dr. Doctor Name(s), I realized that I may have a genetic link to Lipedema. My mother/sister/aunt/grandmother was diagnosed with/meets the criteria for having Lipedema. My mother/sister/aunt/grandmother had the classic abnormal fat distribution in their extremities, and suffered many of the complications of Lipedema including lymphedema, excessive bruising, sensitivity and pain on palpation, painful swelling, cellulitis infections, decreased mobility, restricted movement, osteoarthritis, and joint pain that severely reduced their quality of life. Due to the pain of Lipedema, they were on disability/took daily pain medications/unable to care for themselves/unable to work/etc.

My Lipedema Causes Me Pain & Decreases My Mobility

I suffer from the typical complaints for stage I/II/III/IV Lipedema. I have symmetrical lipedemic fat accumulation affecting my calves/thighs/legs/hips/buttocksarms/lower abdomen/pubic region with my feet and hands being spared. I have [insert symptoms - see symptom list for examples]. My torso is disproportionately thinner. I experience swelling (non-pitting edema) with numbness and tingling in my extremities and have a negative Stemmer’s sign. I have osteoarthritis/decreased mobility/gait issues due to excess Lipedema weight. I suffer from chronic pain/fatigue/depression/body dysmorphia/disordered eating. I have been unable to lose fat in my affected areas despite diet and exercise. My mobility has suffered due to instability and pain, and I’m losing my ability to take care of myself and meet my daily needs. My daily pain ranges from #1-10 on good days to #1-10 on bad days, on a scale from 1 (no pain) to 10 (worst pain).

If someone wanted to understand what Lipedema feels like, I’d ask them to strap a gallon milk jug to each of their thighs and a half gallon to each of their calves. I’d then ask them to walk around in public, experiencing the instability caused by the liquid sloshing in the jug, making their gait unsteady and slow. With it, feeling the pain of walking just a short distance from the unnatural movement and the extra weight on the hips, knees and feet. Also, feeling self-conscious and depressed about the judgmental stares of strangers, and frustration about being disabled and/or less mobile than they know could or should be if they didn’t have milk jugs (or lipedemic fat) on their legs.

INSERT PHOTOS WITH CAPTIONS HERE

HIGHLIGHT DISPROPORTIONATE BUT SYMMETRICAL FAT DEPOSITS, NEGATIVE STEMMER'S SIGN, SWELLING, ANKLE/WRIST CUFFING, CREASING, VARICOSE VEINS, BRUISES, VISIBLE NODULES/LIPOMAS, NODULAR OR "MATTRESS" TEXTURE, OVERHANGING FAT DEPOSITS, AND HIGHLIGHT ANY AREA WITH NORMAL FAT ACCUMULATION SUCH AS NECK & CHEST OR UNAFFECTED LIMBS/TORSO

My Lipedema Is NOT Lifestyle-Induced Obesity

My annual testing with my primary care doctor confirm my diagnosis of Lipedema and rules out other possible conditions. My A1C/cholesterol/thyroid values/blood pressure are consistently within the normal range, while my inflammatory markers are high. I do not have metabolic syndrome and I am not in the at-risk range for future metabolic syndrome. My excess adiposity is limited to my calves/thighs/legs/hips/buttocks/abdomen/arms/pubic region. My feet are spared from excess fat accumulation, as are my head/face/neck/chest/abdomen/back. You can easily visualize/palpate my collarbone/ribcage/shoulder blades/spine upon examination.

RING SIZE EXAMPLE With my hands being spared from excess fat, as is typical of Lipedema, my fingers are slender and my wedding ring size is considerably small at only a size 5. Research has found a positive correlation between second and fourth finger length (2D:4D ratio) with obesity, and my 2D:4D ratio is within the non-obese range.

NECK CIRCUMFERENCE EXAMPLE My neck is also spared from fat accumulation, with a circumference of only 30cm. Research indicates that a neck circumference greater than 36cm for women was associated with lifestyle-induced obesity.

Section III Research Appendix:

• Neck circumference can differentiate obese from non-obese individuals (Lucas, Fonseca & Dantas)

• Relationship Between Second to Fourth Digit Ratios and Obesity, Muscle Mass (Golge, Sivaslı, Pazarcı, Goksel, Kaymaz, Kuloglu)

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Appeal Section IV: Liposuction is Safe

• Use this example Liposuction is Safe as a general template

• Color Key:

  • • Fill in your personal information where there are red text

    • Text in purple are suggestions; remove any irrelevant suggestions

    • Text in blue are examples; re-write or remove any irrelevant examples

• This section aims to educate your insurance company on liposuction for lipedema, and can be largely left untouched; if you suffer from lymphedema or another condition of concern to the insurance company, summarize relevant reserach linking that condition and the safety of liposuction

YOUR NAME

INSURANCE COMPANY NAME ID #000000000

1ST APPEAL REQUEST

IV. LIPOSUCTION IS SAFE AND THE ONLY EFFECTIVE TREATMENT FOR LIPEDEMA

Peer-Reviewed Research: Liposuction for Lipedema is Safe, Effective

The abnormal fat deposits that accumulate in one's body from Lipedema cannot be lost through diet and exercise, or even weight loss surgery. The only known safe and effective treatment to prevent the progression of Lipedema, improve functional mobility, and reduce future disability and morbidity is surgical intervention aimed at removing the abnormal, diseased adipose tissue from the patient's body. Liposuction is currently accepted by medical professionals worldwide as the standard of care for treating Lipedema, and has been the treatment of choice in Germany for over 20 years.

Circumferential liposuction has been proven to reduce pain, non-pitting edema, sensitivity to pressure and bruising, while improving gait, mobility, range of motion, ADL’s, and quality of life in Lipedema patients. The removal of all diseased adipose tissue by liposuction has also been shown to reduce the stress on lymphatic vessels and improve exercise tolerance. A thorough review of medical literature during the time period between 1982 and 2014 demonstrates that medical professionals consistently agree that liposuction is a safe and effective treatment for adipose tissue diseases such as Lipedema that offers sustained results over time.

It is important to note that this type of liposuction is not traditional liposuction performed as a cosmetic procedure to improve physical appearance. Unlike traditional liposuction, lymph-sparing liposuction removes diseased adipose tissue and is performed in a manner that preserves the structural integrity of the lymphatic vascular system, which is very vulnerable in Lipedema patients. Ideally, a “wet” technique is used (tumescent anesthesia, water jet-assisted) with a smaller vibrating cannula oriented longitudinally to minimize injury to the lymphatic system, precautions that are not routinely taken during cosmetic procedures. Lymph-sparing liposuction is used as a medical procedure to improve functional mobility and reduce pain, swelling, and comorbidities in Lipedema patients and is not for cosmetic benefit.

Conservative methods such as decongestive therapy, diet and exercise modifications, and supplement use can help with some of the symptoms of Lipedema and may prevent its progression, but are not a cure and often don’t resolve the major complaints of Lipedema such as pain and mobility issues. Decongestive therapies are most effective in reducing edema in patients with lipolymphedema, but do not reduce the abnormal adipose tissue. Manual lymphatic drainage massage, compression stockings, and lymphatic pump provide only a temporary benefit of hours or days at best, while liposuction has been proven in the literature to provide a long-term benefit of years or potentially a lifetime. Diet and exercise are important for overall health, but will not reduce the areas of Lipedema fat and therefore are ineffective at resolving many of the complaints of Lipedema patients. Only liposuction resolves these complaints.

Section IV Research Appendix:

· Evaluation and Management of the Fat Leg Syndrome (Warren, Janz, Borud & Slavin)

· Functional and Therapeutic Indications of Liposuction (Atiyeh, Costagliola, Illouz, Dibo, Zgheib & Rampillon)

· Lipedema: diagnostic and management challenges (Peled & Kappos)

· Lipoedema: current aspects of a long forgotten illness (Wollina)

· Liposuction: A Surgical Tool to Improve the Quality of Life after Morbid Medical Conditions (Elkhatib)

· Liposuction in the Treatment of Lipedema (Dadras, Mallinger, Corterier, Theodosiadi & Ghods)

· Liposuction is an Effective Treatment for Lipedema (Rapprich, Dingler & Podda)

· Liposuction of Lipedema to Prevent Later Joint Complications (Stutz)

· Long-term benefit of liposuction in patients with lipoedema (Baumgartner, Hueppe & Schmeller)

· Long-term Outcome After Surgical Treatment of Lipedema (Peled, Slavin & Brorson)

· Specialist approaches to managing lipoedema (Fetzer)

· Treatment of lipedema by low-volume micro-cannular liposuction in tumescent anesthesia (Wollina & Heinig)

· Treatment of lipoedema using liposuction (Rapprich, Baum, Kaak, Kottmann & Podda)

· Tumescent liposuction in lipoedema yields good long-term results (Schmeller, Hueppe & Meier-Vollrath)

· Water-Jet Assisted Liposuction for Patients with Lipoedema (Stutz & Krahl)

Section IV Reference Appendix:

· Liposuction Principles and Practice - Chapter 3: Lipedema and Lymphatic Edema (Shiffman Di Giuseppe)

Liposuction Will Treat My Lipedema and Prevent Further Disability

Liposuction will adequately treat my Lipedema and improve my mobility and ADL’s, as evidenced by the extensive body of research on liposuction to treat Lipedema. It will allow me to care for myself again, including returning to work/continuing to work/reentering the workforce in my desired/trained field and earning an income; caring for young children/disabled family members/aging parents; bathing/dressing/grooming/cooking/cleaning without assistance; getting into vehicles or onto doctor’s tables without assistance; being able to walk, sit and stand longer and climb stairs; decreasing the likelihood of falls and injuries; delaying the need for joint replacements, and decreasing the likelihood of further disability including becoming immobile. It will also reduce my future risk of developing metabolic syndrome and other comorbidities.

My Surgeon Is Qualified to Treat My Lipedema with Liposuction

Dr. Doctor Name is qualified to perform the medically necessary treatment for my condition. They are experienced with Lipedema/lymphedema/other conditions patients and the surgical reduction of abnormal adipose tissue. They are a graduate of School/University and trained/completed their residence in plastic surgery/reconstructive surgery at the facility/hospital. They have gone over the procedure in detail with me, and are committed to preserving my lymphatic functioning while resolving my Lipedema and associated complaints. They have addressed conservative treatments with me such as decongestive therapy/compression garments/vein procedures/etc. and have reviewed my history in detail to ensure there are no contraindications for liposuction. We are in agreement that liposuction is the best treatment option for my Lipedema.

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Appeal Section V: My Liposuction is Medically Necessary

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• Look up your state's medical code that defines what "medically necessary" means

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YOUR NAME

INSURANCE COMPANY NAME ID #000000000

1ST APPEAL REQUEST

V. LIPOSUCTION IS A MEDICALLY NECESSARY TREATMENT FOR MY LIPEDEMA TO IMPROVE MY PAIN AND MOBILITY AND PREVENT FURTHER DISABILITY

STATE CODE EXAMPLE Arizona Administrative Code (AAC) Section R9-22-202.B.1 states that AHCCCS only pays for services that are “medically necessary” or will help the patient get better, and services must be the most “cost effective” that will give the patient the same result. The code defines “medically necessary” as meaning “a covered service is provided by a physician or other licensed practitioner of the healing arts within the scope of practice under state law to prevent disease, disability, or other adverse health conditions or their progression, or to prolong life."

In Insurance Company’s 2022 Evidence of Coverage Manual, it states medically necessary “means that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.” Furthermore, it states that Mercy Care will pay for “medically-necessary medical care or surgery services furnished in a physician’s office, certified ambulatory surgical center, hospital outpatient department, or any other location.”

In documenting the medical necessity of liposuction to treat my Lipedema, I noted that I diligently pursued more conservative treatments to manage my disease to no avail. As recommended by my team of physicians and specialists, I dieted, exercised, took supplements, wore compression garments, used a lymphatic pump, completed manual lymphatic drainage massage/decongestive therapy, and had additional testing done to rule out other treatable conditions. My Lipedema did not respond to any of these treatments. Instead, it only progressed as my extremities increased in size, my mobility decreased, and my pain increased, all negatively effecting my ability perform simple tasks of daily living and reducing my quality of life.

As explained in Section IV, the only safe and effective treatment to stop the progression of my Lipedema and provide sustained relief from its symptoms is liposuction. The peer-reviewed, published medical journal articles cited in Sections II and IV support liposuction as an appropriate, safe and effective treatment to reduce pain and swelling, improve function and mobility, improve quality of life, and reduce future disability and early mortality for patients suffering from Lipedema. Liposuction is the only known treatment to remove the diseased adipose tissue and restore function to Lipedema patients, and the medical articles I cited in Sections II and IV show that liposuction is widely accepted by medical professionals worldwide as the standard treatment and care for Lipedema.

COSMETIC DENIAL Insurance Company’s 2022 Evidence of Coverage Manual notes that procedures deemed cosmetic are “covered in cases of an accidental injury or for improvement of the functioning of a malformed body member.” The trusted Merriam-Webster dictionary defines malformed as and “characterized by malformation, misshapen,” and defines “malformation” as “irregular, anomalous, abnormal, or faulty formation or structure.” By this definition, my Lipedema has certainly caused malformation in my extremities that decreases normal functioning as evidenced in sections I-III, and therefore meet’s Insurance Company’s own cosmetic procedure coverage for “improvement of the functioning of a…malformed body member.”

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Appeal Section VI: Erroneous Denial

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YOUR NAME

INSURANCE COMPANY NAME ID #000000000

1ST APPEAL REQUEST

VI. INSURANCE COMPANY'S REASONS FOR DENYING COVERAGE FOR LIPOSUCTION ARE NOT VALID AND ARE NOT SUPPORTED BY MEDICAL EVIDENCE

Insurance Company’s Denial is Erroneous

BMI/OBESITY EXAMPLE Insurance Company, in its denial letter dated Month Date, Year, stated that it is denying coverage of my liposuction surgery due to my BMI being in the “obese range” and the alleged cosmetic nature of the procedure. The denial further states “cosmetic surgery is not a service we pay for. Cosmetic means that it is done to improve a person’s looks. We can only pay for surgery that improves your health.” AHCCCS Mercy Care cites Arizona Administrative Code as part of its legal basis for denying coverage.

As I explained in detail in Section V above, my liposuction surgery meets this state’s legal requirements for being “medically necessary.”

Therefore, Insurance Company cannot deny medically necessary treatment per its contract with its members. Insurance Company “only pays for services that are medically necessary, or will help you get better,” and that those medically necessary services “must be the least costly service that will give you the same result.” As more conservative treatments have been tried and there are no other widely available procedures to treat Lipedema, liposuction also meets the requirement of being the least costly service. Additionally, my surgery meets Mercy Care’s requirement that the surgery will improve my health and help me get better as it will improve my daily functioning, mobility, pain, and quality of life while reducing the chance of future disability and comorbid conditions such as lymphedema, metabolic syndrome, and other conditions associated with later stage Lipedema.

Lipedema Is A Disease State/Chronic Health Condition With Which I Have Been Diagnosed, As Demonstrated By Medical Evidence

My diagnosis of Lipedema has been confirmed by at least ## medical professionals and is accepted and recognized by my treating team of physicians and specialists.

My medical records demonstrate I have exhibited definitive symptoms of stage I/II/III/IV Lipedema – abnormal adipose distribution in my arms/legs that spares my hands and feet with additional abnormal adipose distribution in the hips/buttocks/abdomen/pubic region; painful swelling and sensitivity to touch; easy bruising; numbness and tingling in my extremities; and comorbid conditions that increase my pain and decrease my mobility and ADL’s.

In addition, as is characteristic of Lipedema, this abnormal adipose tissue accumulation continued despite diet, exercise and supplement use under the guidance of medical professionals, compression garment use, lymphatic pump use, and decongestive therapy by a physical therapist. Moreover, other possible causes of my symptoms were ruled out and my other medical conditions are being treated to the accepted medical standard.

The evidence presented herein and in my medical record shows I was correctly diagnosed with Lipedema, and treatment is medically necessary to improve my health, reduce my pain, improve my mobility and daily functioning, and prevent further disability, comorbidities, and immobility.

My Lipedema Causes Functional Impairments

I have presented substantial evidence demonstrating numerous functional problems that I have experienced as a result of my Lipedema. My medical record shows an impaired functioning individual with low quality of life due to the limitations imposed by Lipedema. These limitations include widespread pain and sensitivity, reduced mobility, decreased range of motion, joint pain with future joint replacements indicated, osteoarthritis, tenderness and easy bruising, swelling, numbness and tingling in the extremities, history of falls with and without injury, foot problems, and painful fat movement and creasing. My day to day limitations are numerous, as I am not able to walk, stand, or sit long. I require assistance for almost every task, and am regularly seen by doctors and emergency medicine for the many problems caused by my Lipedema. I have been unable to work since Month Year due to these limitations. My future mobility and ability to care for myself will continue to be negatively impacted by Lipedema if it is not treated promptly.

My Lipedema is Best Treated by Liposuction

The extensive medical research discussed in sections II and IV clearly demonstrates that liposuction is the best treatment for Lipedema, and will offer significant improvements to my functional impairments and prevent further disability in the long term. It is the accepted standard of care for the treatment of Lipedema, and is neither investigational nor experimental. My doctors are in consensus that liposuction is the best option for my Lipedema to stop its progression, restore my function and mobility, reduce my pain, and prevent further disability.

Sections V & VI Reference Appendix:

· Arizona Administrative Code (Secretary of State)

· Evidence of Coverage Manual (2019 Mercy Care)

· Definition of “malformed” (Merriam-Webster Dictionary)

· Definition of “malformed” (Merriam-Webster Dictionary)

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Appeal Section VII: Conclusion

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YOUR NAME

INSURANCE COMPANY NAME ID #000000000

1ST APPEAL REQUEST

VII. CONCLUSION

Insurance Company is a health plan provider whose mission/vision statement is "quote mission/vision statement." A health plan provider with such pride in its ability to provide high-quality individualized health care for its members surely doesn’t want their members to suffer with rare or misunderstood conditions, yet in denying coverage of my medically necessary surgery in line with the accepted standard of care for my condition, that is exactly what Insurance Company is doing. Insurance Company’s decision, if not overturned, will cause long term suffering and further disability that is well documented in the cited medical literature.

I have attached to this appeal appendices containing my medical records including letters of medical necessity from my treating physicians and copies of all of the research and references cited. The extensive information I have submitted overwhelmingly and clearly demonstrates that liposuction is medically necessary to treat my Lipedema, improve my health, restore my mobility and ADL’s, and prevent further disability. Therefore, I am requesting that Mercy Care or an independent review organization reverse the decision to deny coverage of my procedure promptly so that I may undergo the treatment I need for my condition.

Sincerely,

SIGN NAME

YOUR NAME

CC: State Insurance Commissioner, Lipedema Advocate, Dr. Doctor's Name, Appeals Coordinator Name, Case Manager Name

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LipedemaAdvocate@gmail.com