Liposuction - Medical Necessity Criteria
Criteria for documenting medical necessity of liposuction
Contents:
- How can you get liposuction covered by insurance?
- When is liposuction medically necessary?
- Medical necessity criteria for liposuction
- Does Medicare cover liposuction?
- Health plan criteria for liposuction and other references
How can you get liposuction covered by insurance?
To have liposuction covered by insurance, you must prove that it is medically necessary — that is, you have a medical condition that requires treatment with liposuction. If liposuction is done only for the purpose of improving appearance or self-esteem, it is unlikely to be covered.
When is liposuction medically necessary?
Liposuction may be considered medically necessary for indications such as lymphedema, lipedema, hyperhidrosis, or breast reconstruction when medical necessity criteria are met.
Medical necessity criteria for liposuction
The following may be considered medically necessary indications for liposuction.
In the context of medically necessary breast reconstruction, liposuction may be considered medically necessary for the purpose of harvesting autologous fat:
- as a replacement for implants for breast reconstruction
- to fill defects after breast conservation surgery
Liposuction may be considered medically necessary for the treatment of lymphedema or lipedema when all of the following criteria are met:
- Failure of at least 3 consecutive months of optimal conservative treatment (such as with medical management and compression garments);
- Significant functional impairment (such as difficulty moving around or performing activities of daily living) or medical complication (such as recurrent cellulitis);
- Liposuction is reasonably expected to improve the physical functional impairment; and
- Commitment to wear compression garments and continue conservative treatment after surgery to maintain benefits.
Ultrasonic liposuction for axillary hyperhidrosis may be considered medically necessary when the patient meets all of the following criteria:
- Unresponsive or unable to tolerate oral pharmacotherapy prescribed for excessive sweating;
- Significant disruption of professional and/or social life because of excessive sweating;
- Extra-strength antiperspirants are ineffective or result in a severe rash; and
- Failure to respond adequately to iontophoresis treatment.
Most health plans do not cover the following because they are either cosmetic, not medically necessary, and/or experimental/investigational:
- Liposuction performed to improve a patient’s normal appearance and self-esteem
- Liposuction performed as a component of a gender transition / when used to improve the gender-specific appearance of an individual undergoing gender affirming surgery
- Liposuction of fat deposits considered undesirable, including removal of excess abdominal fat
- Liposuction for obesity
- Liposuction-curettage for hyperhidrosis
- Liposuction-only reduction mammoplasty (breast reduction surgery)
- Liposuction for gynecomastia
- Pubic liposuction
Does Medicare cover liposuction?
Medicare considers the following procedures cosmetic and/or not medically necessary. For that reason, they will not be covered by Medicare.
- Liposuction for the treatment of gender dysphoria
- Liposuction for body contouring, weight reduction, or the harvest of fat tissue for transfer to another body region for the purpose of improving appearance or self-image
When liposuction is used for the treatment of gynecomastia, it is considered a part of the primary procedure and will not be covered separately.
Health plan criteria for liposuction and other references
- Aetna criteria for:
- Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair
- Breast Reconstructive Surgery
- Breast Reduction Surgery and Gynecomastia Surgery
- Cosmetic Surgery
- Gender Affirming Surgery
- Hyperhydrosis
- Lymphedema
- Obesity Surgery
- Anthem Blue Cross criteria for:
- Cosmetic and Reconstructive Services of the Trunk and Groin
- Gender Affirming Surgery
- Mastectomy for Gynecomastia
- Panniculectomy and Abdominoplasty
- Reduction Mammaplasty
- BlueCross BlueShield of Tennessee Policy on Liposuction
- Health Net Criteria for Cosmetic and Reconstructive Surgery
- Medicare
- Local Coverage Article on Gender Reassignment Services for Gender Dysphoria
- Local Coverage Determination on Cosmetic and Reconstructive Surgery
- UnitedHealthcare Criteria for Cosmetic and Reconstructive Procedures