Traditionally, most insurance carriers have not covered cosmetic or body contouring procedures. In the past, the only plastic surgery procedures routinely covered were panniculectomy (after significant weight loss) and breast reduction surgery.
However, at Lipedema MD in West Long Branch, New Jersey, we’ve worked hard to change that. Over several years, we’ve built strong relationships with local and national insurance carriers and educated them about Lipedema and Dercum Disease. We also provide patients with the resources and support needed to navigate the insurance process. As a result, we have successfully helped many of our patients obtain insurance approvals for medically necessary procedures.
Today, approximately 90% of our lipedema patients undergo surgery with insurance coverage.
Insurance Plans We Work With
We regularly receive approvals from the following commercial insurance providers:
- Blue Cross Blue Shield
- Horizon
- Aetna
- Cigna
- UnitedHealthcare
- Oxford
- Empire
- GHI
- Humana
- UPMC
- Other regional plans
What Procedures Are Commonly Approved?
We most commonly receive coverage for:
- Liposuction for lipedema
- Panniculectomy
In some cases, insurance may also cover the removal of excess skin from the arms or legs. Each case depends on your plan, medical documentation, and insurance carrier policies.
How the Insurance Approval Process Works
The approval process can be complex and time-consuming. It typically requires:
- Patient compliance with insurance-specific protocols
- Medical documentation from multiple qualified providers
- Imaging or testing results
- Evidence of conservative treatments attempted
- Peer-to-peer review calls between our surgeons and insurance medical directors
Every insurance plan is different—even between patients with the same carrier. Our office will guide you through the process, but your active participation is essential. Without it, approval is often not possible.
In-Network, Out-of-Network & Gap Exceptions
We are out of network with most commercial insurance plans, but because experienced lipedema surgeons are rare, we often request in-network gap exceptions for specific cases. If granted, this allows your surgery to be covered at in-network rates.
However, even with a gap exception, not all insurance companies disclose their allowed reimbursement rates. In some cases, coverage may be approved but at a rate that does not reflect the complexity or time involved in surgery.
Prepayment for Commercial Insurance Plans
For all insurance-covered procedures, we require prepayment before surgery to cover:
- Your deductible, copayments, or coinsurance
- Any cosmetic or non-covered services you elect to add
- Up to the maximum out-of-pocket limit for your benefit level
If a single-case agreement is reached, your financial responsibility is limited to your deductible and cost-sharing. If not, your case may be processed under out-of-network rules, which can impact reimbursement.
Medicare, Medicare Advantage, and Federal Plans
Traditional Medicare does not recognize lipedema surgery as medically necessary and does not offer a preauthorization pathway. We are currently unable to provide surgery under traditional Medicare.
Medicare Advantage, TRICARE, and VA-based plans may cover some services but typically:
- Do not disclose reimbursement rates
- Require patients to prepay the surgeon’s fee
- Provide reimbursement (if any) after the fact
- Cover facility, anesthesia, and testing in most cases
If reimbursement is received, it is credited or refunded back to the patient up to the allowed amount.
Medicaid Coverage
Medicaid plans vary by state. Some HMO-based Medicaid plans may cover the surgeon’s fee, while traditional Medicaid often does not. In cases where coverage is allowed:
- We require prepayment of the professional fee
- Reimbursement (if provided) is returned to the patient
- Single-case agreements may be an option in select circumstances
Understanding How Insurance Coverage Is Determined
Approval decisions are based on multiple documents—some of which patients rarely see:
Summary Plan Description (SPD)
- Written by your employer
- Explains what services are covered and what rules apply
- Legally overrides anything a representative might say
- The most important document for determining your rights
Medical Policy for Lipedema
Published by your insurance carrier (if available)
Lists criteria for coverage
Helps us predict the approval process
Local Coverage Determination (LCD)
- Used by Medicare and related plans
- Lipedema surgery is not currently recognized in LCDs, which is why Medicare does not cover it
Cash Pricing and Financing Options
If you don’t have insurance, are denied coverage, or choose not to go through the approval process, we offer:
- Transparent cash-pay pricing
- Third-party financing to help make treatment more accessible
Independent Insurance Advocacy
Insurance coverage for lipedema can be particularly complex for patients on self-funded employer plans. In some cases, we may recommend outside support from independent insurance advocacy consultants.
- These services are optional
- They are paid directly by the patient
- They are not billed or managed by our office
Why Choose Lipedema MD for Lipedema Treatment?
Lipedema MD specializes in the diagnosis and surgical treatment of lipedema with a level of expertise that’s hard to find elsewhere. Dr. Boris Volshteyn and Dr. Rudolf Thompson are board-certified plastic surgeons with decades of combined experience in advanced liposuction techniques, lymphatic preservation, and complex body contouring. Every treatment plan is built around your medical needs and long-term goals—not cosmetic outcomes.
We also understand that lipedema care goes far beyond the operating room. That’s why we guide patients through every step, from insurance navigation and documentation to recovery and long-term follow-up. Our practice offers the tools, experience, and support you need to move forward with confidence.
Get the Support You Need to Move Forward
Navigating insurance for lipedema surgery can feel overwhelming, but you don’t have to do it alone. Our team is here to help you understand your benefits and pursue coverage.
For questions or assistance, contact Lipedema MD in West Long Branch at (732) 641-3350.
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