A federal judge in California certified a class action lawsuit against Aetna on April 26 from at least 23 members who claim the CVS Health subsidiary denied them coverage for medically necessary liposuction treatments.
The members are covered under Employee Retirement Income Security Act health plans administered by Aetna. They claim the payer denied their liposuction treatments for lipedema, a condition that involves an abnormal buildup of fat tissue, typically in the lower body, and causes pain and mobility issues.
The plaintiffs claim Aetna's coverage policies included a general exclusion for cosmetic or plastic surgery, with no exceptions. Under the policy, liposuction is only considered medically necessary during breast reconstruction and after meeting certain criteria. The policy was effective from 2015 to April 2020.
In 2018, Aetna denied one of the plaintiff's requests to cover her liposuction for lipedema, writing "this procedure is meant to improve appearance, not to correct a physical problem that affects your daily activities." The company also denied two additional appeals.
The plaintiff originally filed the lawsuit in 2019, but the judge dismissed it and the plaintiff filed an amended complaint. In 2020, Aetna revised their coverage policies to specifically include lipedema as a medically necessary reason for liposuction.
Because Aetna did not notify members of the coverage change or reprocess any previously denied liposuction claims, the plaintiff filed for class certification in 2021.
The two parties disputed the size of the class, however. According to the plaintiff, it stood at "at least" 25 people, based on information provided by Aetna. Aetna contended the class included no more than 15 members.
"The bottom line is this: the class size appears to be either 25 members or 23," the judge wrote.
The judge ruled the plaintiff sufficiently met all criteria to certify the lawsuit as a class action.
"Kazda has sufficiently shown, at least for the purposes of class certification, that Aetna considered suction lipectomy a cosmetic procedure and denied class members' claims on those grounds," the judge wrote. "This evidence undermines Aetna's argument that it had no categorical or uniform policy denying claims for lipedema surgery as cosmetic."
The class action is seeking three types of injunctive relief: an order requiring Aetna to toss its internal coverage policies that classified liposuction as cosmetic, an order for Aetna to change its claims process and reprocess previous coverage denials, and an order requiring Aetna to notify members of the changes to its claims process.