A Simple, Life-Changing Procedure
“The day my buffalo hump was removed through a simple liposuction procedure was life changing. I got instant relief. It was like I was normal again.”
Michael Achille, a resident of South Orleans, Massachusetts, began developing severe lipodystrophy in 2001-2002 as a result of his HIV medication.
Michael’s lipodystrophy manifested itself as a buffalo hump, a fat pad on the back of his neck that grew and quickly became debilitating. The abnormal fat accumulation caused his head to pitch forward and caused significant pain, including splitting headaches and terrible backaches. The buffalo hump made sleeping and driving very difficult, as he could not lie on his back nor turn his head easily. While pain medication such as Vicodin helped alleviate some of the symptoms, this was not the long-term solution he was hoping for.
Eventually, Michael’s doctor told him there was a simple procedure that would provide him with relief: liposuction to remove the buffalo hump. Unfortunately, MassHealth denied his surgeon’s request for prior authorization. His surgeon urged Michael to appeal, and he did, gathering documentation from all his medical providers to prove the medical necessity of treatment.
Michael went to the appeal hearing in Taunton, and he couldn’t believe the response: the MassHealth doctor stated that Michael’s pain and debilitation didn’t matter. The hearing officer even made the Finding of Fact that his “lipodystrophy causes sleep disturbance, debilitating headaches and backaches, as well as psychological distress.”
Despite this, the Appeal decision goes on to state, “The MassHealth representative noted that it is not a question of whether the appellant needs this procedure or can benefit from it but rather one of the requested service not being a covered service by Massachusetts.” As a result, the hearing officer denied Michael’s appeal without even considering whether the surgery was medically necessary. Her hands were tied.
“I was so upset and didn’t know what to do,” Michael says. Fortunately, he was able to find a lawyer to represent him for free. The lawyer filed a Request of Rehearing directly with the Medicaid Director, Dr. Julian Harris, making the case for medical necessity as well as legal arguments in favor of treatment. Michael was relieved when he learned that Dr. Harris determined that Michael should receive liposuction surgery.
“The day my buffalo hump was removed through a simple liposuction procedure was life changing,” Michael explains. “I got instant relief. I was delirious with joy. It was like I was normal again.”
Michael is sharing his story because he knows it is not possible for everyone who needs this treatment to make an appeal and find a lawyer to take their case directly to the Medicaid Director for consideration. In fact, many people don’t seek treatment, because they’ve heard it’s not covered and therefore don’t know what to do.
Michael was lucky, but medically necessary treatment shouldn’t be left up to luck.