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.

Overview of the Insurance Process 

There are three main steps involved in the insurance process:

1. Prior Authorization 

This is the stage where the insurance reviewer determines whether the submitted surgical codes are considered medically necessary. 

The decision of medical necessity is critical, as it impacts every step that follows—including potential reimbursement. For services to be approved as medically necessary, the patient must meet all criteria established by their insurance provider.

2. GAP Exception Request 

This step involves requesting that Dr. Schwartz and TLC Surgical Center be considered in-network. Achieving in-network status is required before moving on to the next step: the single case agreement. 

What if the GAP is denied? 

If the insurance provider claims there are other in-network providers who can perform lipedema reduction surgery, they will provide a list of those physicians. 

It is the patient’s responsibility to contact these providers and verify: 

• Whether they actually treat lipedema (not lymphedema) 
• Their level of experience treating the condition 
• How long they have been managing lipedema patients 

Insurance lists are often inaccurate, and some providers may have no experience treating lipedema. 

Please document: 

• The name of the person you spoke with 
• Their responses 

This information can be used to support an appeal with your insurance company.

3. Single Case Agreement (SCA) 

This is an agreement between the surgeon and the insurance company regarding payment. 

An approved single case agreement is the best-case scenario, as it significantly reduces the patient’s financial responsibility for both the procedure and operating room costs.

Alternative Option: Cash Pay with Reimbursement 

If you meet all medical necessity criteria but are unable to obtain approval for Step 2 or 3, you may still proceed with treatment through a cash-pay option. 

• You will be provided with a cash price for your surgical plan 
• After the procedure is completed, you may submit a claim for reimbursement ● Insurance does not allow reimbursement requests prior to surgery 

Important notes about reimbursement: 

• Claims must be submitted by the patient directly 
• Reimbursement checks are sent to you, not the office 
• Our office will provide all necessary documentation, including: 

○ Superbills for the procedure 

○ Operating room fees 

○ Anesthesia 

While we support you through this process, reimbursement amounts are not guaranteed. Some patients have received up to 90% reimbursement, while others have received around 20%, depending on their insurance plan. 

How to Contact Other Providers (If Needed) 

When calling providers listed by your insurance, you may use the following script: 

“Hi, I’m calling to gather information about procedures performed by Dr. [Name]. I’d like to know if they specialize in connective tissue disorders such as lipedema (not lymphedema). 

My insurance has listed Dr. [Name] as an in-network provider, and I want to confirm whether they treat lipedema and how frequently they see patients with this condition.” 

If the provider does treat lipedema, follow up with: 

• What surgical technique is used (e.g., water-assisted, VASER, or power-assisted liposuction) 
• Whether manual extraction is performed for larger nodules 
• How long the doctor has been treating lipedema patients 
• Whether they are involved in research or published literature on lipedema