Lipedema denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for suction assisted lipectomy of the bilateral arms and bilateral legs with associated hospitalization.Researchers report that lipedema is believed to affect 11% to 39% of the female Caucasian population worldwide, and that as many as 16 million women in the United States may be affected with the disorder. Researchers state, “Lipedema is an uncommon disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The adiposity extends from hips to ankles and is typically unresponsive to weight loss. In addition to the aesthetic deformity, women also describe pain in the lower extremities, particularly with pressure, as well as easy bruising.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for suction assisted protein lipectomy (SAPL). Reich-Schupke and colleagues state, “The diagnosis [of lipedema] is established on the basis of medical history and clinical findings. Characteristically, there is a localized, symmetrical increase in subcutaneous adipose tissue in arms and legs that is in marked disproportion to the trunk. Other findings include edema, easy bruising, and increased tenderness. Further diagnostic tests are usually reserved for special cases that require additional workup.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) bilateral lymph sparing liposuction to upper and lower extremities and trunk and (2) excision of excessive skin/subcutaneous tissue to bilateral thigh, legs, arms and trunk. Warren Peled and Kappos state, “Lipedema is an uncommon disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The adiposity extends from hips to ankles and is typically unresponsive to weight loss. In addition to the aesthetic deformity, women also describe pain in the lower extremities, particularly with pressure, as well as easy bruising.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for lipedema and panniculectomy surgeries.The authors of a study stated that lipedema is an uncommon disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The adiposity extends from hips to ankles and is typically unresponsive to weight loss. In addition to the aesthetic deformity, patients also describe pain in the lower extremities, particularly with pressure, as well as easy bruising. One of the major distinguishing features of lipedema is the sparing of the feet, which can create a distinct step-off at the ankle.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving lipedema, then check the rights and deadlines that apply to your plan.