J Obstet Gynaecol. Ann Chir Plast Esthet. Most patients are pleased with the functional and aesthetic outcome following surgery. Care must be taken when planning a surgical intervention, and support from plastic or general surgery may be required. Larson GM. 2018;38(12):NP196-NP204. Unlike with standard liposuction (a cosmetic body-contouring procedure that removes relatively small areas of stubborn fat), the goal of therapeutic liposuction is to remove as much fat as possible. Does Lipedema Fat Come Back After Surgery ? This includes mapping venous and lymphatic structures, using ultrasound during liposuction to help "visualize" the lymphatics, employing surgical techniques that orient the cannula lengthwise rather than across, and using very generous tumescent infiltration. Medial thigh lift and partial lower abdominoplasty with minimal undermining were used to correct skin laxity and prevent intertrigo (intertriginous dermatitis). The American Society for Aesthetic Plastic Surgery (ASAPS) survey: Current trends in liposuction. ALT's dedicated insurance team, with over 40 years of experience, worked tirelessly to secure coverage for lipedema patients, at no cost to . Dr. Thomas Wright, a specialist in venous and lymphatic medicine and a lipedema expert, practicing inOFallon, Missouri, refers to the treatment for this medical condition as lipedema reduction, because we dont want to imply cure or elimination of lipedema., Dr. Wright advises his patients that surgery must go hand-in-hand with a healthy lifestyle. Medicare does not cover liposuction surgery that people undergo for cosmetic reasons. The mean amount of lipoaspirate in the LPARSP group was 1,054 613.5 ml. We know how to overcome the roadblocks to getting your insurance company to pay fairly for your medically necessary treatment. Copyright 2020-22 Coverlipedemaco, Inc. All Rights Reserved. Micheau P, Grolleau JL. Papers were individually reviewed for their utility and applicability to the management of adult ABP. This Clinical Policy Bulletin may be updated and therefore is subject to change. 2013;33(7):1021-1029. Coverage is your right. Prior to surgery, your circulation should be assessed to ensure that your blood supply is healthy enough to allow appropriate healing, as well as to minimize any risk from the procedure from abnormal blood vessels that often are present in the affected areas. The authors detailed the causes of buried penis, and their approach for surgical repair of buried penis in complex cases. Reich-Schupke and co-workers (2017) noted that the revised guidelines on lipedema were developed under the auspices of and funded by the German Society of Phlebology (DGP). This disease process is characterized by a wide degree of variability and severity that requires a patient-specific approach and significant flexibility on the surgeon's behalf. Photographs must be submitted along with the findings. Youll be encouraged to be up and walking around by the day after lipedema surgery. Ann Plast Surg. ", Such was the experience with RealSelf member Lipedema Lady, who reports that "the difference in my legs is striking, both in appearance and functionality. 2016;4(9):e1043. It is likely that lipedema is frequently mis-diagnosed or wrongly diagnosed as only an aesthetic problem and therefore under- or mis-treated. Lipoabdominoplasty: Liposuction with reduced undermining and traditional abdominal skin flap resection. The authors concluded that little consistent information concerning either diagnostics or therapy could be found in the literature. I just got all my surgeries pre-approved with a Single Case Agreement thanks to the amazing help from coverlipedema.com., Read more of what our members say about us. 2014;7:35-42. The pooled mean operating time was 192.2 mins and the mean estimated blood loss (EBL) range was 57 to 326 ml. Ramirez OM. The high incidence of graft-related complications should be taken into account when counselling patients and AABP care should be centralized to high-volume centers. The most exciting thing this month was a California Medicaid plan that agreed to pay $7,000 per surgery - a great base for fair payment. Aetna considers surgical correction of adult acquired buried penis medically necessary when the following selection criteria are met: The buried penisengulfs the entire penis, documented by high-quality color frontal-view and side-view photographs; The medical records document that the buried penis causes. Its perfect for grabbing the attention of your viewers. Mortality following laparoscopic ventral hernia repair: Lessons from 90 consecutive cases and bibliographical analysis. Abbed TM, Gonzalez-Heredia R, Sanchez-Johnsen L, et al. It is relatively resistant to weight loss and can proliferate with even a small calorie excess.". Despite the emergence of laser-assisted liposuction, to-date, it has not been clearly evaluated combined with abdominoplasty. Aetna considers liposuction medically necessary in persons with pain and disability from lipedema who have failed to respond to three or more months of conservative management (compression or manual therapy) and who meet the following diagnostic criteria for lipedema: Medical History Pain and hypersensitivity to touch in lipedema affected areas; At the three-month mark, most people see about 5060% of their final improvement. These researchers reported a case of a patient with lipedema who was treated with suction-assisted lipectomy and use of compression garments, with successful treatment of the lipodystrophy and maintenance of improved aesthetic results at 4-year post-operative follow-up. All of the following must be submitted: Bilateral symmetric adiposity (fat accumulation) in the affected extremities. Aesthetic Plast Surg. When Americans are working, they pay into Medicare through their years of employment. A telltale difference between the two conditions: Lymphedema can affect any body area, including the hands and feet, while lipedema will stop (or cuff) at the wrist or ankle. The Lipedema Surgery Center in Roswell GA partners with Prosper Healthcare Lending to provide patients with low, negotiated, financing fees. Evaluation and management of adult acquired buried penis. Petro CC, Zolin S, Krpata D, et al. Currently, the best known treatment for lipedema is surgery of one form or another. Copyright 2020-22 Coverlipedemaco, Inc. All Rights Reserved. Other findings include edema, easy bruising, and increased tenderness. These conservative trialsinclude diet changes, daily medical-grade compression stocking use and/or compression with special wrapping techniques, andmanual lymphatic drainage, a gentle form of skin stretching and massage. A total of 170 studies were identified and screened, and 21 studies (570 patients) were included. Other Policies and Guidelines may apply. Supportive use of adipose-derived stem cells in cell-assisted lipotransfer for localized scleroderma. 2004;8(3):208-212. The goal of the surgery is to take out as much fat and fibrous tissue as possible without further damaging the lymphatic system. Coleman WP 3rd, Lawrence N. Liposuction. Am I Overweight, Or Do I Have Lipedema Fat? Dumanian GA, Denham W. Comparison of repair techniques for major incisional hernias. Patients with lipedema stage II and III showed better improvement compared with patients with stage I. Published March 1, 2022 Updated June 13, 2022, Consult with a doctor virtually or in person, your surgeon's credentials and level of expertise, whether you need more than one procedure, to achieve your desired results, the qualifications of your anesthesia provider. Manuscripts focusing on pediatric patients were excluded. how the proliferation and differentiation process of ADSC can be regulated in-vitro and in-vivo; which factors control the proliferation and differentiation of ADSC; the predominant factors controlling the proliferation and differentiation process of ADSC; which factors stimulate ADSC to secrete paracrine factors; whether transplanted ADSC are tumorigenic; and. Waltham, MA: UpToDate;reviewed January 2016. Promotion of a healthy lifestyle with individually adjusted weight control measures, graded activity training programs, edema reduction, and other supportive measures are pillars of conservative therapy. Doctors didn't believe her when she said she was constantly dieting . Throughout her life, Kristy has been told she was obese and needed to lose weight. Most patients can return to work in two weeks and fully get back to normal activities, including workouts, in up to six weeks. There is no way I could have managed this on my own. World J Surg. Moustaki M, Papadopoulos O, Verikokos C, et al. Laloze J, Varin A, Gilhodes J, et al. UpToDate [online serial]. Safety of a modified lipoabdominoplasty technique for donor-site cosure in abdominal-based free flap breast reconstruction. Dtsch Arztebl Int. Lipedema is a disease, and surgery to treat it is covered by health insurance. Wounds UK. Aetna is not a provider of health care services and therefore is not responsible for and does not guarantee any results or outcomes of the covered health care services and supplies you receive. In elderly patients with advanced lipedema, correction of increased skin laxity has to be considered for an optimal outcome. Patient selection optimization following combined abdominal procedures: Analysis of 4925 patients undergoing panniculectomy/abdominoplasty with or without concurrent hernia repair. And my legs feel lighter and oddly, my balance is better. If you can pinch and lift the skin, Stemmers test is negative. A systematic review. Application of adipose-derived stromal cells in fat grafting: Basic science and literature review. The effectiveness and safety of combining laser-assisted liposuction and abdominoplasty. Your application will be reviewed within hours. Abdominal skin sensation, objective functional and aesthetic measures of the abdomen, as well as patient-reported outcomes (Breast-Q), were analyzed. Aesthetic Plast Surg. The authors concluded that liposuction was effective in the treatment of lipedema and led to an improvement in QOL and a decrease in the need for conservative therapy. STEER: Succint and Timely Evaluated Evidence Reviews. Atiyeh B, Costagliola M, Illouz YG, et al. 1997;99(5):1462-1463. When combined with post-operative weight loss, surgical repair of buried penis can greatly benefit patients by improving urinary and sexual function in addition to their mental and psychological well-being. It is characterized by increased fat stores in the buttocks and legs. Frequently, people with lipedema are misdiagnosed with obesity and told to go on a diet and exercise. Tumescent liposuction is the treatment of choice for patients with a suitable health profile and/or inadequate response to conservative and supportive measures. Wollina U, Heinig B, Nowak A. Falcone M, Sokolakis I, Capogrosso P, et al; European Association of Urology (EAU) guidelines working on Male Sexual and Reproductive Health and EAU-Young Academic Urologists (EAU-YAU) Sexual and Reproductive Health Working Group. Medicare covers mostly the acute conditions, the conditions that are quick to resolve. Lipedema is a chronic, progressive disorder marked by the individual variability and unpredictability of its clinical course. Furthermore, the LPARSP group presented with a decreased bulging rate (p = 0.05), and secondary refinement procedures were less frequently demanded (p = 0.02). Toyserkani NM, Quaade ML, Sorensen JA. Coverage Rationale . Expect to feel pressure, but no pain, while the fat is being extracted. Update from the Ultrasonic Liposuction Task Force of the American Society for Dermatologic Surgery. Staalesen T, Elander A, Strandell A, Bergh C. A systematic review of outcomes of abdominoplasty. The authors concluded that a tailored approach may be useful in advanced lipedema and was applicable even in elderly patients with multiple co-morbidities. Facility fee (e.g., ambulatory surgery center) 25% coinsurance Not covered None Physician/surgeon fees 25% coinsurance Not covered None 080700-090020-252257 Page 2 of 6. Hernia. what causes ADSC to become liquefied in-vivo. Superior functional and aesthetic results paired with improved abdominal wall sensation were achieved compared to CA. 2017;15(7):758-767. 2015;75(2):231-245. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. We work with medical insurance companies every day to get them to cover lymph sparing liposuction for our lipedema patients. They called and emailed all the top dogs and legal counsel from the insurance company, my employer and the third party that my employer hires to handle their insurance issues. 1999;44(4):443-461. Don't be alarmed, though: leakage from incision sites is completely normal. Pham C, Middleton P, Watkin S, Maddern G. Laparoscopic ventral hernia repair: An accelerated systematic review. Cardenas-Camarena L, Gonzalez LE. Further diagnostic tests are usually reserved for special cases that require additional work-up. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. 1998;102(5):1698-1707. Matarasso A, Matarasso SL. These investigators also noted that the limited proliferation capacity of ADSC also prevented their widespread clinical use; ADSC lack telomerase and their telomeres are short; thus they can only proliferate in-vitro for a limited period of time. ANZ J Surg. Wollina and associates (2014) noted that In advanced stages of lipedema, reduction of adipose tissue is the only available effective treatment. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. Systematic review and meta-analysis. Micro-cannular laser-assisted liposuction of the upper legs and knees was performed under tumescent anesthesia. I go into more detail in this article, but you might have to pay for your surgery out of pocket, since most insurance plans don't cover liposuction for lipedema. Tumescent liposuction. 2014;134(4):539e-550e. Grabin S, Antes G, Bjorn Stark G, et al. This prospective study aimed to evaluate the safety and effectiveness of laser-assisted liposuction relative to traditional liposuction combined with high-lateral-tension abdominoplasty. Plast Reconstr Surg. 1999;42(1):34-39. If present, morbid obesity should be therapeutically addressed prior to liposuction. Because of the higher pressure from the affected areas, vein disease and lymphatic problems often occur simultaneously. Br J Surg. Post-surgical care with non-elastic flat knitted compression garments and manual lymph drainage were used. Rhinoplasty - Rhinoplasty is a nose job. Lipedema: A relatively common disease with extremely common misconceptions. When performed by an experienced provider, lipedema surgery risks are low. Simply click here to complete an application online. As the fat cells continue to enlarge, they may also affect the blood vessels, causing circulatory system problems. Does Insurance Pay for Lipedema Surgery? Danilla S, Longton C, Valenzuela K, et al. Monday: Closed Rey LE, Koch N, Raffoul W. Surgical treatment for lipedema. 2004;74(6):504-506. Dr. Byrd says, There are two insurance companies that have been accepting coverage for Lipedema surgery and that is Blue Cross and Aetna. Buried penis can be associated with poor cosmesis and hygiene, voiding dysfunction, and sexual dysfunction. According to the Cleveland Clinic, lymphedema treatments wont help someone with lipedema, which almost always gets worse without treatment. Umeadi UP, Ahmed AS, Murphy J, Slade RJ. That's because these rogue cells have extra fluid, which distorts the skin and changes its size, shape, color, texture, and sensitivity. Expect significant swelling in the treated areas for the first few weeks after surgery. In rare cases, Medicare may cover a cosmetic surgery like liposuction if it's medically. Abdominal hernias. 2016;40(2):309-318. According to Dr. Wright, all insurers also require a trial of three to six months of conservative treatment to manage symptoms. If you need cataract surgery in both eyes . If your claim is denied, we will also assist you through the appeal process and participate in a peer- to- peer interview if required. According to the Lipedema Foundation, surgery is the only available lipedema treatment option to correct this abnormal fat tissue. Therefore, it is reasonable to perform allografts using the ADSC from younger individuals. Si vous ne souhaitez pas que nos partenaires et nousmmes utilisions des cookies et vos donnes personnelles pour ces motifs supplmentaires, cliquez sur Refuser tout. Aesthetic Plast Surg. These investigators reviewed the current evaluation and surgical management of this rare and complex patient population. J Plast Reconstr Aesthet Surg. Dermatol Surg. Proximal thickening of subcutaneous fat layer; Distal thickened of subcutaneous fat, accompanied by slender instep (cuff-sign). Technology Assessment. Cooter R, Robinson D, Babidge W, et al. Stanley Rockson co-authored a paper that identified a biomarker for lipedema, a little understood fat disorder that is often confused with obesity. Depending on your skin's elasticity and the amount of fat extracted, you may be left with loose, sagging skin. 2017;79(5):495-497. Cell-assisted lipotransfer: A critical appraisal of the evidence. . Incisional hernia. 2012;46(3-4):139-144. Elbaz JS, Flageul G, Olivier-Masveyraud F. 'Classical' abdominoplasty. 2019;64(3):237-244. Laparoscopic versus open ventral hernia repair:A randomized controlled trial. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. North Adelaide, SA: Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S); 2004. Byrd says, "There are two insurance companies that have been accepting coverage for Lipedema surgery and that is Blue Cross and Aetna. Apfelberg DB. Aetna considers suction lipectomy cosmetic for indications other than lipedema and lymphedema. ASERNIP-S Report No. Talk with your insurer about their requirements for coverage. It is an increasingly common problem seen by reconstructive urologists and these researchers presented several frequently seen scenarios of buried penis and management options. 1998;24(3):397-400. "Awareness of lipedema is poor," says Dr. Wright. abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) [documentation required], Localized adiposity [abdomen] [documentation required], Erythema intertrigo [chronic, documentation required], Excessive and redundant skin and subcutaneous tissue, Separation of muscle, (non-traumatic) other site [diastasis recti], Other congenital malformations of abdominal wall [congenital diastasis recti], Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy, Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh, Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg, Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip, Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock, Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm, Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand, Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad, Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area, Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure), Suction assisted lipectomy; head and neck, Suction assisted lipectomy; upper extremity, Suction assisted lipectomy; lower extremity, Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area [Correction of adult acquired buried penis], Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra [Correction of adult acquired buried penis], Meatotomy, cutting of meatus (separate procedure); except infant, Circumcision, using clamp or other device with regional dorsal penile or ring block, Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less), Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age, A thinning out of the anterior abdominal wall fascia, Dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing. However, it is important to know, the patient must go through a protocol prior to surgery so they can meet the requirements of being approved. The most important part is to get pre-qualification from the insurance prior to having surgery. 2018;7(4):618-627. Plast Reconstr Surg. We know how to overcome the roadblocks to getting your insurance company to pay fairly for your medically necessary treatment. Ann Chir Plast Esthet. For Aetna plans that cover bariatric surgery, here is a summary of the criteria for gastric bypass approval: S1 guidelines: Lipedema. Group 3 underwent laser-assisted liposuction with abdominoplasty. Surgeons entered into single case agreements covering the full costs of surgery for several Aetna members as well as UHC, BCBS of Arizona and Highmark BCBS. Summary of Benefits and Coverage: 2023 TX Aetna CVS Silver: Houston HMO CSR 94 ON Standard J Dtsch Dermatol Ges. Nous, Yahoo, faisons partie de la famille de marques Yahoo. Aesthet Surg J. women get over 40 million dollars of lipedema surgery fully covered. "Liposuction can give relief in size reduction, but it often doesnt make the lower extremities look much better," says Dr. Mats Hagstrom, a plastic surgeon in San Francisco. Bragg TW, Jose RM, Srivastava S. Patient satisfaction following abdominoplasty: An NHS experience. A total of 25 patients who received 72 liposuction procedures for the treatment of lipedema completed a standardized questionnaire. New method of abdominoplasty for morbidly obese patients. Sanchez LJ, Bencini L, Moretti R. Recurrences after laparoscopic ventral hernia repair: Results and critical review. A 2019 study on 111 patients with advanced lipedema treated with liposuction over a 10-year period found that serious adverse events occurred in 1.2% of procedures, the infection rate was 0%, and the bleeding rate was 0.3%. Dermatol Surg. No severe adverse effects were observed; and patient satisfaction was high. St. Paul, MN: HTAC; 2002. This Coverage Policy addresses surgical treatments for lymphedema and lipedema. Ottawa. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile. It can take up to a year for all the swelling to resolve, so you can see your final results. "The insurer may cover lipedema surgery in the some areas where lipedema tissue collects, but not all of the areas of body where lipedema tissue can occur," he says. Dont let the insurance process discourage you. 2012;45(1):77-88. During your recovery (and ideally beyond), you'll be wearing compression garments, to help reduce swelling and encourage your skin to heal smoothly over your new contours. An assessment of surgery for lipedema by the Canadian Agency for Drugs and Technologies in Health (CADTH, 2019) (Peprah and MacDougall, 2019) reached the following conclusions: "Evidence of limited quality from five uncontrolled before-and-after studies suggests that liposuction may be effective in reducing the size of the extremities and complaints associated with lipedema such as spontaneous pain, easy bruising, sensitivity to pressure, impairment in quality of life, restrictions to mobility, edema, feeling of tension and general impairment. High definition lipoabdominoplasty. We are here every step of the way to do whatever we can to try to get your procedures covered. Common Medical Event . 1997;21(4):285-289. 2008;78(10):903-906. BenefitsProsper Healthcare Lending Provides: Prosper Healthcare Lending is the premier financing company in the healthcare industry with over $4 billion borrowed and over 250,000 people served. O'Brien JJ, Glasgow A, Lydon P. Endoscopic balloon-assisted abdominoplasty. In general, high-complexity reconstructive procedures (category greater than III) were performed, with split-thickness skin grafts for shaft reconstruction. Concomitant abdominoplasty and laparoscopic umbilical hernia repair. 2008;18(12):1605-1610. Individual must respond to at least three consecutive months of medical management. Lorsque vous utilisez nos sites et applications, nous utilisons des, authentifier les utilisateurs, appliquer des mesures de scurit, empcher les spams et les abus; et. Plast Reconstr Surg. Dadras and associates (2017) examined the outcome of liposuction used as treatment for lipedema. At present, there appeared to be an enormous potential for the application of liposuction in ablative and reconstructive surgery outside the realm of purely aesthetic procedures. Am J Surg. Dermatol Surg. Quality of life usually improves greatly after surgery. In a retrospective study, these researchers examined whether post-SG patients who received abdominal lipectomy achieved greater percent excess weight loss (% EWL) than post-SG patients who did not receive abdominal lipectomy. The mean follow-up times for the 1st post-operative follow-up and the 2nd post-operative follow-up were 16 months and 37 months, respectively. Results of multicenter study of laser-assisted liposuction. In equivocal cases, the extra findings (III) can establish the diagnosis. However, some discomfort and bruising for at least 2-3 weeks is expected. Recently, Aetna has denied a few coverage requests and seems to be focusing on documentation for conservative measures. Aetna has covered lymph sparing liposuction for patients with lipedema before and this policy update makes it more likely that they will cover it in the future but there always be restrictions. Aboelatta and colleagues (2014) stated that lipoabdominoplasty is nearly a daily aesthetic procedure. This systematic review was carried out according to the PRISMA guidelines. Aetna started covering lipedema in the Fall of 2019. Singapore Med J. "After liposuction, the nodules become even more apparent. Ahmad J, Eaves FF 3rd, Rohrich RJ, Kenkel JM. Aetna considers repair of a true incisional or ventral hernia medically necessary. Friday: 8:30 am 5:30 pm 11050 Crabapple Road 2006;30(1):1-8. "Studies have shown that most physicians fail to recognize the disease in patients who present to them with symptoms related to lipedema. Aesthetic Plast Surg. Local and IV sedation or general anesthesia. "Lipedema fat is different biologically from non-lipedema fat. Collaboration with multiple surgical services is often needed to achieve optimal outcomes. To adequately debulk, lipedema reduction surgery uses a small blunt cannula to remove larger volumes over larger areas in a procedure thats significantly longer than cosmetic liposuction, explains Dr. Wright. The authors concluded that surgical management of AABP had a high incidence of complications but resulted in satisfactory outcomes, with significant improvement in patients' QOL. J Plast Surg Hand Surg. Links to various non-Aetna sites are provided for your convenience only. 2008;121(5):1821-1829. Pring CM, Tran V, O'Rourke N, Martin IJ. ASERNIP-S Report No. Thickened subcutaneous fat in the affected extremities bilaterally and symmetrically (legs, thighs, hips or buttocks, or occasionally arms are affected); Tenderness and nodularity of fat deposits in lipedema affected areas (dimpled or orange peel texture); Stemmer sign negative (Stemmers sign is negativewhen a fold of skin can be pinched and lifted up at the base of the second toe or at the base of the middle finger) (unless the member has comorbid lymphedema); Absence of pitting edema (no pitting when finger or thumb pressure is applied to the area of fat) (unless the member has comorbid lymphedema); Evidence of "cuffing" (tissue enlargement ends abruptly at ankles or wrists, with sparing of hands and feet) (also called "braceleting" or "inverse shouldering").
