CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

Lipectomy or Suction-Assisted Lipectomy

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This policy governs coverage, medical necessity, prior authorization, limitations, and exclusions for lipectomy and suction-assisted lipectomy across applicable Health Plan products. Coverage may apply when specific clinical criteria are met, including treatment of lipedema or breast reconstruction.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyLipectomy or Suction-Assisted Lipectomy

Policy CodePolicy N/A

Change TypePolicy update

Effective DateJune 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests through the Health Plan provider portal for applicable members.

SourceLink

POLICY UPDATE CHANGES

Prior authorization is not required when the member has a breast cancer diagnosis.

Align, Align DSNP, and Great Plains Medicare Advantage plans were added to the policy effective January 1, 2026.

Commercial criteria were transitioned to InterQual, and reviews are completed through InterQual.

5Required lipedema criteria elements

≥3 monthsMinimum refractory symptom duration

RequiredPrior authorization for most requests

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CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

Lipectomy or Suction-Assisted Lipectomy

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Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyLipectomy or Suction-Assisted Lipectomy

Policy CodePolicy N/A

Change TypePolicy update

Effective DateJune 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests through the Health Plan provider portal for applicable members.

SourceLink

POLICY UPDATE CHANGES

Prior authorization is not required when the member has a breast cancer diagnosis.

Align, Align DSNP, and Great Plains Medicare Advantage plans were added to the policy effective January 1, 2026.

Commercial criteria were transitioned to InterQual, and reviews are completed through InterQual.

5Required lipedema criteria elements

≥3 monthsMinimum refractory symptom duration

RequiredPrior authorization for most requests

No PABreast cancer diagnosis authorization exception

ExcludedFamily Health Center coverage

ExperimentalMetabolic syndrome or post-bariatric weight loss

Medical Necessity and Coverage Criteria

Lipedema medical necessity

Suction-assisted lipectomy and lipectomy are medically necessary for lipedema when all of the following are met:

All required criteria

Pain and hypersensitivity: There is specific documentation of pain and hypersensitivity to touch in lipedema-affected areas of the trunk.
Bruising history: There is a history of easy bruising or bruising without apparent cause in lipedema-affected areas of the trunk.
Response to weight loss: There is a relative lack of effect of weight loss on lipedema-affected areas of the trunk.
Fat-deposit findings: There is tenderness and nodularity of fat deposits in lipedema-affected areas of the trunk, with a dimpled or orange-peel texture.
Failure of conservative treatment: Symptoms have been refractory to conservative treatment.>= 3 months

Integral part of another covered service

Services may be covered when the technique is an integral part of another covered service.

Integral covered service: The suction-assisted lipectomy or lipectomy technique is an integral part of another covered service.

Coverage depends on the underlying service being covered.

Breast reconstruction

Lipectomy or liposuction may be medically necessary for breast reconstruction when the applicable breast reconstruction criteria are met.

Breast reconstruction: Lipectomy or liposuction is performed for breast reconstruction and the applicable criteria are met.

See the Breast Reconstruction Post-Mastectomy policy for the applicable criteria.

Medicare Advantage therapeutic exception

Medicare Advantage coverage may be available when surgery is therapeutic, even if it also happens to serve a cosmetic purpose.

Therapeutic exception: The surgery is performed for a therapeutic purpose that coincidentally also serves some cosmetic purpose, and the applicable coverage criteria are met.

Medicare otherwise considers these services cosmetic and not covered. For Align, Align DSNP, and Great Plains, coverage criteria follow Commercial guidelines because Medicare has not released an applicable NCD or LCD.

Reduction mammoplasty performed by liposuction is not covered. Refer to the Breast Reduction Mammoplasty policy for applicable coverage criteria.

Abdominoplasty and panniculectomy are addressed under the Cosmetic Surgery/Treatments and Panniculectomy policies rather than this policy.

Lipectomy and suction-assisted lipectomy are excluded under the Family Health Center product.

There is no coverage for lipectomy or suction-assisted lipectomy under the Federally Facilitated Exchange Individual Policy, Select EPO, or under the specified Small Group products: Tradition HMO, Independence POS, Reliance EPO, and Freedom Indemnity.

Lipectomy is not covered when the Health Plan determines that it serves a cosmetic purpose or is otherwise not medically necessary. Suction-assisted lipectomy of the trunk is considered cosmetic for indications other than lipedema and lymphedema.

Services that do not meet the clinical criteria listed in this policy are denied as not medically necessary. Services for which the policy does not provide applicable clinical criteria are considered experimental or investigational.

Authorization, Documentation, and Denial Risks

Prior Authorization

Submit commercial prior authorization

Commercial members require prior authorization. Submit the prior authorization request through the Health Plan provider portal using the Prior Authorization Request form.

Prior Authorization

Obtain Medicaid authorization

BadgerCare Plus and Medicaid SSI require prior authorization. Submit the request through the Health Plan provider portal and follow applicable ForwardHealth coverage and prior authorization guidelines.

Prior Authorization

Route Medicare Advantage requests through InterQual

Medicare Advantage plans require prior authorization through the Health Plan provider portal. For Align, Align DSNP, and Great Plains, review is completed through InterQual and coverage criteria follow commercial guidelines because Medicare has not issued an applicable NCD or LCD.

Clinical Background

Suction-assisted lipectomy, also called abdominal contouring via liposuction, removes fat beneath the abdominal skin to improve appearance. Lipedema may be classified by the affected area, including the region between the belly button and hips, pelvis and knees, pelvis and ankles, shoulders and wrists, or knees and ankles.

Terms and Procedure Definitions

Lipectomy

DefinitionLipectomy is surgical removal of fatty tissue.

Procedure typeLipectomy is a surgical procedure.

Tissue addressedThe procedure removes fatty tissue.

Lipedema

DefinitionLipedema is an abnormal fat buildup on both sides of the lower body.

Typical locationsIt usually affects the legs but can also affect the arms.

Characteristic presentationLipedema can cause pain and make daily activities difficult; it does not respond to diet and exercise like ordinary fat.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyLipectomy or Suction-Assisted Lipectomy

Policy CodePolicy N/A

Change TypePolicy update

Effective DateJune 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests through the Health Plan provider portal for applicable members.

SourceLink

On This Page

Prior Authorization

Submit TPA authorization requests

Third Party Administration requests require prior authorization. Submit the request through the Health Plan provider portal; review is completed through InterQual.

Documentation Required

Document the lipedema findings

For lipedema treatment, document all required clinical findings: pain and hypersensitivity to touch, easy or unexplained bruising, relative lack of effect of weight loss on the affected areas, and tenderness and nodularity of fat deposits with a dimpled or orange-peel texture.

Document symptoms in lipedema-affected areas of the trunk.
Document symptoms refractory to conservative treatment for greater than or equal to 3 months.

Documentation Required

Establish trunk involvement and treatment failure

Document that the affected areas are lipedema-affected areas of the trunk and include the associated clinical findings. The record must also show that symptoms have been refractory to conservative treatment for at least 3 months.

Pain and hypersensitivity to touch
Easy bruising or bruising without apparent cause
Relative lack of effect of weight loss
Tenderness and nodularity with dimpled or orange-peel texture
Failed conservative treatment for ≥ 3 months

Documentation Required

Verify Medicaid coverage and authorization guidance

For BadgerCare Plus and Medicaid SSI, use the ForwardHealth Physician Handbook and applicable fee schedule to verify payable services, provider types and specialties, places of service, coverage criteria, and prior authorization guidelines.

Coverage criteria: Physician Handbook → BadgerCare Plus & Medicaid → Physician → Covered and Noncovered Services → Surgery Services → Panniculectomy and Lipectomy Surgeries.
Prior authorization criteria: Physician Handbook → BadgerCare Plus & Medicaid → Physician → Prior Authorization → Prior Authorization Guidelines → Panniculectomy and Lipectomy Surgeries.

Documentation Required

Review the TPA plan document

For TPA groups, review the member’s Summary Plan Description to determine whether the services are covered and whether limitations or exclusions apply. If the SPD does not contain specific guidelines or criteria, TPA groups that use the Health Plan to process services follow commercial criteria.

Denial Risk

Prevent a medical necessity denial

Services that do not meet the stated clinical criteria will be denied as not medically necessary. Lipectomy is not covered when the Health Plan determines that it serves a cosmetic purpose or is otherwise not medically necessary.

Services without listed clinical criteria are considered experimental or investigational.
Document the applicable medical necessity criteria before requesting authorization.

Denial Risk

Do not use abdominal lipectomy for these indications

Abdominal lipectomy for treatment of metabolic syndrome or as an adjunctive procedure to assist with long-term weight loss following bariatric surgery is considered experimental and investigational because of insufficient evidence of effectiveness.

Denial Risk

Establish a covered trunk indication

Suction-assisted lipectomy of the trunk is considered cosmetic for indications other than lipedema and lymphedema. Cosmetic services are not covered under the policy.

Billing Rule

Do not bill liposuction as covered reduction mammoplasty

Reduction mammoplasty performed by liposuction is not covered. Refer to the Breast Reduction Mammoplasty policy for applicable requirements.

Denial Risk

Check for the Family Health Center exclusion

Lipectomy and suction-assisted lipectomy are a policy exclusion for Family Health Center members. Requests for these services under that product are not covered.

Denial Risk

Check specified Exchange product exclusions

There is no coverage for lipectomy or suction-assisted lipectomy under the identified Federally Facilitated Exchange products. Verify the member’s product before submitting the request.

Individual Policy, Select (EPO)
Small Group Policy, Tradition (HMO)
Small Group Policy, Independence (POS)
Small Group Policy, Reliance (EPO)
Small Group Policy, Freedom (Indemnity)

Suction-Assisted Lipectomy

DefinitionSuction-assisted lipectomy is a surgical procedure designed to remove fat under the abdominal skin to improve appearance.

Alternate terminologyIt is also called abdominal contouring via liposuction.

Treatment areaThe procedure removes fat beneath the abdominal skin.

Lipedema Types

Type IFat is between the belly button and the hips.

Type IIFat is between the pelvis and knees.

Type IIIFat is between the pelvis and ankles.

Type IVFat is between the shoulders and wrists.

Type VFat is between the knees and ankles.