Lipedema (Lipoedema) 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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for suction-assisted lipectomy to remove fat and other tissues of the trunk and arms. Lipedema is a chronic, progressive disorder of subcutaneous adipose tissue that usually affects the lower extremities. The benefits of suction lipectomy for the treatment of patients with lipedema are well established. These benefits include better ambulation and quality of life, and improvement in pain and tenderness. One study collected data from women who had undergone lipedema reduction surgery to determine if they experienced improvement in their quality of life, pain, and other measures.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lipedema surgery- suction assisted lipectomy to posterior hips and buttocks with excision of skin excess and thigh nodule, lateral thigh liposuction to address nodules in the lateral thigh, medial thigh and medial calf and excision of excess medial thigh skin are not reconstructive in nature for the treatment of this patient. One 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.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for additional lipedema reduction surgeries consisting of suction-assisted lipectomy of the (1) circumferential torso; (2) calves/ankles/upper arms; and (3) circumferential thighs. Sandhofer and colleagues 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. 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.

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 (lipoedema), then check the rights and deadlines that apply to your plan.