Insurance Coverage Tips

These tips are general tips for acquiring coverage for the treatment listed, they are not condition specific.  Given the unique and less known nature of our conditions, more than likely initial coverage requests will be denied. The highly automated claims process contributes to this also, if diagnosis codes and treatment codes do not match what is in the computer the claim may be denied. Do not get discouraged in you are denied, request an appeal and remember to focus on the medical necessity of the service or product requested.


All insurance policies vary by company, and by employer the most accurate way to verify specific coverage information is to call the customer service on the back of your ID card; however, verbal information is not binding. ALWAYS ask for the written policy, your employer should provide you with the Plan Document, and the insurance company should provide any specific internal policies. Most of this information is available online; you might have to register with your insurance company website to access it. Otherwise, per request a hard copy should be mailed or e-mailed to you.

Manual Lymph Drainage (MLD)

MLD should be performed by either a Physical Therapist or Occupational Therapist who is certified in lymphatic massage. If you intend to file a claim with your insurance carrier, please consult your insurance policy, as insurers may be more likely to cover therapy by certified specialists.The insurance benefits for MLD may fall under your Outpatient Rehabilitation Therapy benefits.  Insurance plans often limit the number of visits for Outpatient Therapy, limitations could be per type, for example 20 Physical, 20 Occupation, 20 Repertory, OR overall 60 visits total. Note that typically insurance will only cover the therapist services, and not the wraps, and materials needed for compression wrapping. If you find you need additional visits to complete therapy request them, it is essential that MLD be continuous as to not lose progress made.

Compression Garments, Sleeves, & Pumps   

Compression garments, sleeves, and pumps are considered Durable Medical Equipment (DME). Every insurance policy should have a specific section outlining coverage for DME. Coverage and yearly limits vary by plan. Compression garments for Lymphedema or Lipedema are not “elastic stockings” which are typically not covered by insurance. Compression garments are medically necessary, have your physician state that in writing to the insurance company if needed. Some vendors do not accept assignment for compression garments, so you might find that you have to pay upfront and submit a claim yourself. As for most DME the vendor should get pre-authorization for the items you need and you should be aware of your out of pocket expenses such as co-insurance or co-payment before the items are ordered.

Liposuction

You should consult with your physician to determine whether, under the specific circumstances surrounding your condition and how it impacts your functioning and daily living activities, liposuction is an appropriate procedure for you.   Your physician can also determine whether liposuction could qualify as “reconstructive surgery,” which may be covered by your insurance policy, as opposed to “cosmetic surgery,” which may not be covered.
Insurance policy guidelines can be located on the insurance company website or by calling the customer service number on your ID card and requesting the “reconstructive vs cosmetic surgery policy”.