In early 2022 I went through the lengthy and frustrating process of applying for provincial health coverage for my medically necessary lipedema surgeries and their resulting skin excision surgeries. After many months and many frustrating and unnecessary obstacles posed by the province, I was able to secure approval for my surgeries.
Manitoba Health approved multistage lipedema liposuction surgery with a provider in the USA. Only 6 months later after I underwent 3 surgeries in the USA paid by Manitoba Health, MB Health revoked coverage without medical evidence or reason. This action violates the Insured Health Services Act and is the subject of an ongoing appeal and legal battle in Manitoba.
As of October 2023, this matter remains unresolved and discussions with the Province of Manitoba are ongoing.
There are several barriers to accessing care or approval for the medically necessary surgical care for lipedema. There is much work to be done to help eliminate these barriers and I hope that soon we will have the opportunity to make changes in all provinces at the government level.
The steps according to Manitoba Health:
The following information is taken directly from Manitoba Health’s website. https://www.gov.mb.ca/health/mhsip/oop.html
Out-of-Province Medical Referrals
Sometimes, a patient needs medical treatment or care that cannot be provided in Manitoba. Manitoba Health and Seniors Care may cover some of the costs of this care, based on a specific approval process.
You may be eligible for help with costs related to getting medical care in another province or country when:
- an appropriate physician recommends that you need a necessary, specific medical service (i.e., care or treatment); and
- that treatment is not available in Manitoba.
What is an “appropriate physician”?
An appropriate physician means a Manitoba specialist. A specialist is a doctor who focuses on a certain area of medicine (for example, a physician who specializes in treating heart disease or cancer). “Appropriate” means that the specialist’s field of expertise is related to the patient’s disorder (for example, an obstetrician, or pregnancy specialist, cannot make a neurological, or nerve disorder referral).
Specialists can diagnose and assess very specific illnesses and conditions. They are also likely to know where the treatment and expertise that a patient requires is available.
What is the approval process?
Your family doctor may decide it is necessary to refer you to a specialist. The specialist will assess your condition or illness and may prescribe treatment.
If the prescribed treatment is not available in Manitoba:
- the specialist must write a letter to Manitoba Health and Seniors Care, and provide certain information about your case;
- Manitoba Health and Seniors Care will review the letter from the specialist, and seek an opinion from a medical consultant if necessary;
- after reviewing your case, Manitoba Health and Seniors Care will write back to the specialist to approve or deny coverage for out-of-province treatment. You will also receive a copy of this letter.
In emergencies (e.g., life-threatening cases, such as an organ transplant), this process can be handled very quickly.
Do not arrange for doctor appointments, transportation or any other care-related services until your doctor’s referral request is approved. If you do not have prior approval, you may be held responsible for any costs you incur.
Does it matter where my doctor refers me?
Yes. Manitoba Health and Seniors Care will pay for care or treatment in the United States only if all Canadian medical resources have been exhausted. In some cases, documentation (i.e., proof) that you have seen other Canadian specialists may be required before your request for referral outside the country will be considered.
What costs are covered if I am approved for treatment outside Manitoba?
In Canada:
- Doctor bills – The Manitoba government has made arrangements with all other Canadian provinces and territories (except Quebec) to send bills for medical care directly to Manitoba Health and Seniors Care for payment. In most cases, you do not have to pay any out-of-pocket expenses for approved medical services provided in Canada.
- Hospital bills – Similar arrangements apply to hospital care. If you are admitted to a hospital anywhere in Canada, Manitoba Health and Seniors Care will pay the standard ward rate on your behalf.
In the United States:
If you are referred for medical care outside Canada, and your referral is approved, you may have to pay some of the costs for your medical and hospital services.
For medical and hospital services provided in the U.S., Manitoba Health and Seniors Care will cover:
- doctor bills, at the same rate a Manitoba doctor would receive for similar services; and
- hospital bills, up to 75 percent of insured hospital services.
If your costs for medical and hospital services exceed these coverage limits, it is your responsibility to pay the difference, unless you qualify for special assistance based on financial hardship. This is because costs for such services in the U.S. are generally much higher than costs for the same services in Canada.
What about travel costs?
If your out-of-province referral is approved, you may be reimbursed for reasonable transportation costs. Accommodations, meals, taxis, ambulance and other expenses are not covered. Also see: Travel Subsidy for Out-of-Province Medical Referrals.
What if I need an escort?
Travel costs for an escort may also be reimbursed if the escort is required for your well-being and safety during travel. If an escort is required, your specialist must notify Manitoba Health and Seniors Care by including that information in his or her initial letter of request.
How do the bills get paid?
- Doctor and hospital bills – In most cases, the original doctor bills and hospital bills will be sent directly to Manitoba Health and Seniors Care for processing.
- Transportation costs – You must send your original receipts for transportation costs, or a letter requesting mileage reimbursement, to the Out-of-Province Claims Section at Manitoba Health and Seniors Care.
If you have already paid a doctor or hospital bill, you must include in your request for reimbursement the original receipt showing the amount you paid. If you do not include a receipt, Manitoba Health and Seniors Care will pay the doctor or hospital directly.
For more information, call or write:
Out-of-Province Claims
Manitoba Health and Seniors Care
300 Carlton Street
Winnipeg MB R3B 3M9
Telephone: 204-786-7303
Toll-free: 1-800-392-1207 Ext. 7303
Email:
OutofProvinceClaims@gov.mb.ca
The ACTUAL steps that are required to apply for coverage:
It was my experience that Manitoba Health created an obstacle course of unnecessary and unwritten steps as barriers to accessing this life-sustaining surgery. Below I will detail the steps I as a lipedema patient had to go through to access approval for Out-of-Country lipedema surgery in 2022.
1. Obtain a diagnosis of Lipedema from a Manitoba Doctor
There are very few doctors in Manitoba that can offer a diagnosis of lipedema. This issue stems from a general lack of familiarity with lipedema in Canada. Sometimes your family doctor or nurse practitioner can offer you the diagnosis. More often it is experienced physiotherapists, MLD massage therapists, or international doctors that are the ones to provide our diagnosis. If you cannot get your family doctor to provide the diagnosis of lipedema then please consider having your MLD therapist or an international lipedema specialist provide your diagnosis and a letter to your doctor that details your official diagnosis including type and stage (if available).
Bring a copy of your diagnosis letter to your primary care doctor and ask them to ‘confirm’ your lipedema and have it added to your medical record.
How to have your Lipedema diagnosis added/recorded accurately:
Lipedema (official spelling: Lipoedema) has been recognized by the World Health Organization since 2021 and in the ICD-11 coding system, Lipoedema is coded as EF02.2.
For more than a century, the International Classification of Diseases (ICD) has been the basis for comparable statistics on causes of mortality and morbidity between places and over time. Originating in the 19th century, the latest version of the ICD, ICD-11, was adopted by the 72nd World Health Assembly in 2019 and came into effect on 1st January 2022.
In Canada, most provinces are still using previous versions such as ICD 9 or 10. This can make accessing your diagnostic code difficult and often leads to inaccurate codes being used to try to describe lipoedema in your chart.
To overcome this obstacle one of our members suggests bringing this up with your doctors and asking that they record in your chart and write a letter stating:
“This patient/client has been diagnosed with Lipoedema EF02.2 in accordance with ICD-11 coding standards effective Jan 1, 2022.”
2. Obtain a letter of Medical Necessity from your diagnosing practitioner.
The expert that provides you with your lipedema diagnosis will need to write a letter of medical necessity that details the need for both conservative measures (flat knit compression, regular Manual Lymphatic Drainage (MLD), and if applicable multistage lipedema reduction (liposuction) surgery.
Currently, there are no plastic surgeons in Canada who are qualified to perform lipedema surgery, especially for those in the later stages. There are a small handful of cosmetic surgeons that offer ‘liposuction’ to lipedema patients but it is limited to 5 liters (whereas lipedema specialists in the USA and Germany can take up to 15 liters depending on a person’s size).
Your letter of medical necessity must detail that treatment is NOT available in Canada.
3. Consult a Plastic Surgeon in Manitoba for a referral.
Currently, Manitoba Health requires ALL referrals for lipedema surgery to come from a Manitoba Plastic Surgeon. This requirement exists even though none of the plastic surgeons in Manitoba can diagnose, or offer treatment for lipedema. This requirement falls under the Manitoba Health previously stipulated statement regarding an appropriate MB specialist:
“An appropriate physician means a Manitoba specialist. A specialist is a doctor who focuses on a certain area of medicine (for example, a physician who specializes in treating heart disease or cancer). “Appropriate” means that the specialist’s field of expertise is related to the patient’s disorder (for example, an obstetrician, or pregnancy specialist, cannot make a neurological, or nerve disorder referral).”
Manitoba Health refuses to accept a letter for surgical referral from ANY type of doctor other than a local plastic surgeon.
Barriers to accessing a Manitoba Plastic Surgeon: In 2022 Manitoba Health and the section head of plastic surgery in Manitoba instructed all the plastic surgeons in Manitoba not to write referral letters for lipedema surgery as Manitoba Health ‘would not be approving the treatment’.
This action was unethical and harmful to the lipedema community, especially those who are desperately in need of treatment and facing a total loss of mobility and a significant loss of quality of life.
As a result of this action, you may find it very difficult to get a consultation with any plastic surgeon in Manitoba. If you do happen to get a consult with one they may be unlikely to write you a referral letter for this medically necessary treatment.
4. Plastic surgeon to write a referral letter for surgery to Manitoba Health
The letter MUST state the following:
- Confirmation of your diagnosis of lipedema and stage
- A clear statement that your lipedema surgery is medically necessary & not cosmetic.
- A clear statement that the surgical treatment required is NOT available in Canada
- Name the international lipedema surgeon (include their location and address) that you are being referred to for surgery.
- Provide a copy of the doctor-to-doctor referral from the local plastic surgeon to the international surgeon. (submit a copy of the fax or email with the application)
- If you require an escort for surgery for your safety (as you are having major surgery in another country) you doctor must also specify the need for an escort in the initial letter.
5. Await a response letter from Manitoba Health
Manitoba Health and Seniors Care will review the letter from the specialist, and seek an opinion from a medical consultant if necessary; after reviewing your case, Manitoba Health and Seniors Care will write back to the specialist to approve or deny coverage for out-of-province treatment. You will also receive a copy of this letter.
6. Do not proceed with surgery until you have received a response from Manitoba Health
If you proceed with surgery without prior approval from Manitoba Health your claim may not be approved and any hope of being reimbursed may be lost. Understanding many of us cannot afford to wait for life-saving surgery this is a cost you must weigh out for yourself.
7. If you get a denial letter
If denied by Manitoba Health, pursue the appeals process. Bring all narrative documentation, medical reports, lists of conservative treatments, specialist appointment notes (including MLD therapist), and of course ALL scholarly articles for review. As well as cite the precedent of 3 women covered for lipedema surgery in the USA from Manitoba and the 5+ women covered for full surgical course of treatment by the province for Lipedema in British Columbia.
Hope on the horizon
Important things to know:
Manitoba Health and many provinces in Canada are stating that there is not presently high-quality scientific evidence to support lipedema surgery as an insured service treatment. They are referring to a lack of randomized control (RCT) double-blind studies looking at the efficacy of lipedema surgery vs the use of conservative measures only. Lucky for us there are presently several large RCT studies underway with results expected in late 2024 and 2025. This author hopes that with the emergence of high-quality supporting evidence that lipedema surgery is highly effective at reducing suffering, improving mobility, and improving quality of life we will no longer face the difficulty accessing lipedema surgery coverage in Canada.
Check out the LipLeg Study https://pubmed.ncbi.nlm.nih.gov/34717741/
This is not medical advice and you should always consult a doctor to decide what treatments are right for you.
The application process differs from province to province in Canada. These are the steps that worked for me in Manitoba. The fight for coverage is far from over. Together we can make sure we are seen.
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Emma - Life Beyond Lipedema
