Question: When does coverage for treatment not really mean coverage for the treatment?
Answer: When Anthem administers the insurance. Anthem technically has a policy to ostensibly cover Lipedema Reduction Surgery aka liposuction but the amount they will cover for lipedema surgery and the value they assigned to it is so low that it does not even cover the cost of the surgical drapes and gowns.
Prior to having a policy covering lipedema reduction surgery, LRS, Anthem would routinely cover the surgery at a fair market value ranging on average from around $10,000 – $20,000 per procedure for an in-network procedure. In or around 2021, Anthem and the other Blue Cross Blue Shield insurance companies issued a policy to cover lipedema reduction surgery but assigned a value at such a low amount that their coverage would be nearly useless. Anthem now in many cases pays less for lipedema reduction surgery than they pay for an office visit.
Lipedema reduction surgery is a long and taxing surgery, averaging four to five hours. It focuses on maximal debulking of lipedema tissue requiring special skill and precautions to be followed by the surgeon. Lipedema reduction surgery requires many years of training and skill development before optimal results can be achieved. The cost of surgery varies depending on where the surgeon is located, overhead costs, staffing cost, and cost of surgical supplies and equipment.
Results of the cynically low reimbursement for lipedema reduction surgery by Anthem make it impossible for a surgeon to treat lipedema patients at in-network rates and stay in business. As a result, very few and no experienced lipedema reduction surgeons will accept the in-network rate paid by Anthem for Lipedema Reduction Surgery. If an experienced lipedema surgeon wants to treat Anthem patients, they need to be out of network. The very few surgeons who are employed by an extensive hospital system may accept the in-network surgical fee. Still, they will have to break up a single surgery into as many as 20 or more minimal surgeries to compensate for the meager fee in an attempt to receive fair compensation for their time. This approach gives uneven and incomplete results that do not remove enough lipedema tissue to improve mobility. Even the very few surgeons who will accept the unreasonably low reimbursement will often only perform the surgery once or twice a month because they can do other surgeries that provide more reasonable reimbursement rates.
According to Fair Health, lipedema reduction surgery, or lymph sparing liposuction, costs vary significantly across the United States. The total cost ranges from $20,720* in Florida to $65,200 *in California for out-of-network procedures. Here is a closer look at costs in various locations:
Compare this to the Anthem in-network fee of ~$180, which is obviously ridiculously low. But what about out-of-network fees? Anthem wants/insists that out-of-network surgeons accept their unreasonably low in-network rates.
Anthem will cynically offer a very low in-network rate to out-of-network providers. This unfair reimbursement is why almost all lipedema surgeons are out-of-network. Anthem will not negotiate a fair rate in a single-case agreement for the surgery based on reliable, fair valuations.
A good part of the problem is that Anthem and other commercial insurers use the cosmetic CPT codes 15877, 15878, and 15879 which have no AMA/CMS assigned value. Lipedema reduction surgery is reconstructive focused on functional and mobility improvements and NOT cosmetic concerns. There currently is not, nor will there likely ever be, a value or RVU assigned to liposuction CPT codes 15877, 15878, and 15879 because they are cosmetic codes and will never have an RVU value assigned AMA/CMS RUC Committee. The cosmetic liposuction codes are intended to be used on normal BMI individuals with a BMI of 25 or less. The average, BMI of a lipedema patient is 40 and many have a BMI of greater than 50. The average time spent on a smallish cosmetic liposuction is one hour. Longer and more complex cosmetic liposuction procedures may take two hours. The average time for lipedema reduction surgery is four to six hours (see lipedema reduction surgery paper).
The skill involved in lipedema reduction surgery is much greater than cosmetic liposuction. Great care must be taken to not injure the lymphatics which includes a different surgical technique and equipment. This includes Doppler ultrasound mapping of the venous and lymphatic structures to ensure proper orientation prior to beginning a procedure. Generous tumescent anesthesia is absolutely required. Small, blunt cannulas are used, which requires a great deal of time to remove the tissue. The lipedema tissue is more fibrous and requires more work to debulk. Since there is no specific code for Lipedema reduction surgery and the commercial insurers insist on using a cosmetic code with no official value assigned to it, insurers like Anthem are able to pay less than an office visit for a 4- 6-hour surgery.
Pre-authorization approval for lipedema reduction surgery from Anthem is nearly worthless. Anthem will cover only a such a tiny fraction of the cost that patients with Anthem Insurance need to plan that they will be paying for all, or nearly all, of the cost of the lipedema surgery. Because Anthem reimburses so little for the surgery lipedema patient may consider spreading out the surgeries over several years to just one or two surgeries a year.
