Lipedema reduction surgery, a critical procedure for restoring mobility and reducing pain in patients with lipedema, often faces significant hurdles regarding insurance coverage. One of the primary obstacles is that many insurance carriers use an incorrect cosmetic code for this surgery, knowing it needs to be the proper classification. This tactic allows them to avoid fair reimbursement rates, making it easier to deny claims or write policies that exclude coverage altogether.
Insurance companies frequently insist on using CPT code 15879, a code designated for cosmetic liposuction, even though lipedema reduction surgery is functional and reconstructive. This is a major problem because the cosmetic code has no assigned value through the American Medical Association (AMA) or Centers for Medicare & Medicaid Services (CMS), allowing insurers to pay whatever they want—often far less than what is fair for such a complex surgery.
By categorizing it under a cosmetic code, insurers can deny the surgery more easily. They can claim it’s elective and not medically necessary or is for cosmetic or vanity reasons. This strategic misclassification leaves patients with few options, forcing them to pay out of pocket for life-changing surgeries that should be covered as essential medical care.
Despite being a distinct and necessary medical procedure, lipedema reduction surgery does not have a specific CPT code. Dr. Wright, a leading expert in the field, has proposed a new code, but it has yet to gain significant traction. Insurers can continue to misuse cosmetic codes without a dedicated code, further complicating reimbursement.
Lipedema reduction surgery is a long, complex procedure, typically lasting 4 to 5 hours. It focuses on removing the fibrous, painful lipedema tissue, which requires not only specialized surgical techniques but also years of training and experience to achieve optimal results. The complexity of this surgery far surpasses that of typical cosmetic liposuction or even other vascular surgeries, which often take only one to two hours. Yet, the reimbursement rates for lipedema surgery are shockingly low.
While similar vascular surgeries are reimbursed at $3,000 to $4,000, lipedema surgery takes six to eight times as long but often does not receive fair compensation from insurers. This disparity in reimbursement does not reflect the time, skill, and specialized care required for the procedure.
Due to the cynically low reimbursement rates offered for lipedema reduction surgery, many surgeons simply cannot afford to accept insurance at in-network rates. The surgical fee is so low that very few surgeons can treat lipedema patients while staying in business. As a result, most experienced surgeons specializing in lipedema surgery operate out-of-network, leaving patients with hefty out-of-pocket expenses.
Large hospitals often employ surgeons who accept in-network rates, and to make up for the inadequate fees, they may be forced to break a single surgery into multiple more minor procedures. This approach leads to incomplete results, as these more minor surgeries do not remove enough lipedema tissue to improve a patient’s mobility or quality of life significantly. Moreover, these surgeons may only perform a few lipedema surgeries before switching to better-reimbursed procedures, limiting access to lipedema patients’ care.
According to FAIR Health, lipedema surgery costs vary widely across the United States, with the total cost for out-of-network procedures ranging from $20,720 in Florida to $65,200 in California. Despite these significant costs, insurers typically refuse to negotiate reasonable fees with out-of-network surgeons, insisting on offering only the low in-network rate, which is unsustainable for most surgeons. This refusal to negotiate fair rates is a key reason why almost all lipedema surgeons are out of network, forcing patients to bear the financial burden.
One of the core issues is the inappropriate use of the cosmetic CPT code 15879, which has yet to officially assign value or reimbursement guidelines. Insurers insist on this code, even though lipedema reduction surgery is reconstructive and focuses on functional improvements, not cosmetic enhancements.
Liposuction codes like CPT 15877-99 are also cosmetic and not applicable to lipedema patients, who typically have a BMI of 40 or more. These codes were designed for patients with a BMI of 25 or less. The complexity of lipedema surgery far exceeds that of typical cosmetic liposuction, which often takes one to two hours. In contrast, lipedema reduction surgery averages 4 to 6 hours, requiring meticulous care to avoid damaging the lymphatic system and employing specialized techniques and equipment.
Lipedema patients are left in a difficult and unfair position. Without a proper CPT code for the surgery, insurers continue to exploit cosmetic codes, denying claims and paying well below what is necessary to cover the costs of such a complex, time-consuming procedure.
Patients seeking lipedema reduction surgery often face exorbitant out-of-pocket expenses, even though the surgery is critical to improving their mobility, reducing pain, and preventing further complications like secondary lymphedema. With most surgeons operating out-of-network, patients must navigate a broken insurance system that fails to recognize the true medical necessity of the surgery.
Without systemic changes—such as adopting a specific CPT code for lipedema reduction surgery and negotiating fair reimbursement rates—patients will continue to be underserved, and surgeons will remain limited in their ability to provide essential care.
