CALipedema.com
Let's Get Lipedema Surgery Covered in the State of CaliforniaWhat is Lipedema
Lipedema is a debilitating and painful adipose tissue disorder that impacts only women first recognized in 1940, but underdiagnosed for years. California women who have Blue Cross Blue Shield still cannot get treatment. Including federal employees in the state and women with other Blue Cross Blue Shield plans who would like to travel to the state to see the leading surgeons who treat this disease.
Failing to treat lipedema in a timely manner results in a worsening of the condition, damage to the lymphatic system, and other orthopedic and vascular complications. Even in the early stages, women with this disease experience a significant decline in their quality of life. They can’t travel, work, or even play on the floor with their kids and grandkids like other people.
Covering Lipedema
- Failing to treat lipedema in a timely manner results in a worsening of the condition, damage to the lymphatic system, and other orthopedic and vascular complications. Even in the early stages, women with this disease experience a significant decline in their quality of life. They can’t travel, work, or even play on the floor with the kids and grandkids like other people.
- California is the only state that has a broad law requiring coverage of reconstructive surgery resulting from a disease regardless of whether there’s an impact on function. Lipedema is clearly a disease, impacts function, and causes pain.
- Anthem was sued in California federal court for failing to cover lipedema surgery in early 2019. Although the lawsuit targeted self-funded plans, fully funded and government-funded members also were denied care.
- In the Fall of 2019, Anthem issued a coverage policy for lipedema requiring certain criteria to be met for members to have their surgeries covered. Anthem did not widely publish the policy and most members did not learn about it until the Spring of 2020.
- Anthem has approved members for surgery but has refused to allow them to see surgeons out-of-network. Lipedema surgery had been occasionally covered prior to 2018 but issues with coverage caused surgeons to stop taking patients or to go out-of-network.
- Anthem recommends in-network surgeons who are not board-certified plastic surgeons and have no experience with lipedema surgery. This is a 3 hour staged surgery and the lymphatic system can be permanently damaged if a surgeon is inexperienced. The other surgeons that Anthem recommends at Stanford, USC, and UCSD are microsurgeons who perform complex surgeries on cancer patients. They would be willing to work with a few patients a month but cannot provide complex surgery for the inadequate fees that Anthem pays.
- Anthem on the east coast just entered into several single case agreements for members to see an out-of-network surgeon in St. Louis. Anthem representatives there expressed their belief that “laws are just different in California.”
- Blue Shield of California was not sued but has also refused to cover and fairly pay for lipedema surgery. A federal employee, who won coverage and then payment on two separate appeals, was paid $350 for her 3-hour surgery. As with Anthem, there are delays in processing claims and refusals to accept requests from members to process their claims directly since physicians are out-of-network.
- Aetna, which was also sued, is moving forward with contracting with California surgeons to bring them back in the network. Both Aetna and United Healthcare pay surgeons fairly and listen to concerns about network adequacy.
How You Can Help
We need a meeting with Dr. Richard Panhead of the Senate Health Committee ASAP. Several complaints about CA Blue Shield and Anthem are before the CA Department of Managed Care (DMHC). If Dr. Pan gets involved, the DMHC is more likely to pressure these plans to cover lipedema surgery as they are arguably violating California law.
Please contact your state senator by phone and email and ask them to reach out to Senator Pan to arrange a meeting with lipedema stakeholders (advocates, patients, and surgeons). You can name Health Visions (332.203.2292) as the contact entity. Feel free to call and copy Senator Pan and his aide as well: Senator.Pan@senate.ca.gov and Teri.boughton@sen.ca.gov
Please share your short stories about having lipedema and insurance struggles with Senator Pan, Teri, and the DMHC Commissioner Mary Wanterbee (mary.watanabe@dmhc.ca.gov) and head of enforcement Sonia Fernandes (sonia.fernandes@dmhc.ca.gov). Feel free to do this in paragraphs or video. We likely will put up a website as this could take several months to happen. We also would like some media coverage. When talking about lipedema, the National Institutes of Health has an excellent description that you can forward.