Advice for dealing with HMO/Medicare regarding lipodystrophy treatment

[Guest guest]

Hello all,

I'm hoping someone can steer me to the agency that can help.

I have been suffering with lipodystrophy since 1995. It manifests itself mostly as fat deposits on my upper back (buffalo hump), around my chin and neck, on the back of my head, and in the abdomen (protease belly). I have very minor lipoatrophy in my face, probably masked by the fat deposits.

I finally got in to see the plastic surgeon/reconstructive surgeon. She was very optimistic that she could make some dramatic changes to my appearance, thought could not promise it would be permanent or total. I can live with that. After all these years I thought perhaps there was finally hope that I could go out in public without having to feel self-conscous about my freakish appearance.

So the doctor submits the authorization requests for the procedure and the medical group denies the coverage, claiming that the procedure is cosmetic and is not therefore covered by Secure Horizons or Medicare.

I sent off a rather angry note to ask them to reconsider after reviewing California AB 1621 and a letter from the California Department of Managed Health Care that seems to indicate that Medical Directors must consider treatment for HIV-related Lipodystrophy (Lipoatrophy and Fat Accumulation) as reconstructive rather than cosmetic surgery.

My medical group reasons that the procedure that has been proposed (liposuction of the fat deposits and fat injection for the lipoatrophy) is considered cosmetic by Medicare and therefore is not covered. The letter from the Department of Managed Health Care is a memo dated March 14, 2002 and comes from Linares, M.D., Medical Advisor. According to the medical group, there was no followup direction since the letter and since Medicare hasn't recognized lipodystrophy treatment as reconstructive, it is not covered. The representative said that maybe if I were a commercial patient rather than a Medicare beneficiary, AB 1621 might apply. Since I am on Medicare, it doesn't. I tried contacting the contact person listed on the letter - Phillis Soresi, but the email address is no longer valid.

Does anyone have any further clarification or know what agency might have further information? I thought the passage of AB 1621 was supposed to cover this treatment, particularly in light of the letter from the DMHC. Silly me.

Dennis

m.muaddib@...