Author Topic: How I got FFS Paid for by Insurance  (Read 57166 times)

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Offline - Rachel -

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Re: How I got FFS Paid for by Insurance
« Reply #120 on: June 24, 2017, 04:55:01 pm »
I'm about to embark on my FFS journey.

My insurance situation is very different than any of the other posts in this thread. I'm covered by medicare with Washington state employee retiree insurance as secondary. My state has very trans-inclusive policies for insurance companies; a number of companies here cover everything trans-related, including hair removal. My policy specifically excludes FFS and requires that I can only see providers that accept medicare.

I want to see Dr. Zukowski for my FFS; he is not on my preferred provider list and does not take medicare, so it would seem I have no chance of getting any coverage. I'm going to try anyway.

I don't think it's possible to get any kind of pre-approval in my case, so my hope is to file a claim after I get my surgery, then petition medicare to cover it post-op and get my secondary insurance to pick up the out-of-network balance.
I want to get it done as soon as possible. Getting letters supporting medical necessity should not be a problem.

I would love to have an insurance advocate help me navigate this mess, but I'm prepared to go it alone.
I was able to squeak by and get by GRS with Dr. Marci Bowers 1 month before I turned 65 covered by insurance.

Has anyone got medicare to pay for FFS? Any other helpful suggestions?

"Never be bullied into silence. Never allow yourself to be made a victim.
Accept no one's definition of your life; define yourself." -- Robert Frost

Offline stephbertenshaw

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Re: How I got FFS Paid for by Insurance
« Reply #121 on: August 21, 2017, 06:00:51 am »
Hi Jen,

Could you share details about the helpful court rulings provided by Dr. Z? I apologize if you're already done this. I looked for this info in the replies, but gave up because of the length of this thread.

Thanks,

Steph

Offline LizK

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Re: How I got FFS Paid for by Insurance
« Reply #122 on: August 21, 2017, 06:06:00 am »
Dear stephbertenshaw

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Offline AlexisRene

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Re: How I got FFS Paid for by Insurance
« Reply #123 on: September 10, 2017, 09:34:24 pm »
 Many hugs & much appreciation to Jen & all that have shared info in this thread! It is long, but so worth the read. Hope to put it to work in the future!

Offline JLT1

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Re: How I got FFS Paid for by Insurance
« Reply #124 on: September 14, 2017, 08:26:15 pm »
Hi Jen,

Could you share details about the helpful court rulings provided by Dr. Z? I apologize if you're already done this. I looked for this info in the replies, but gave up because of the length of this thread.

Thanks,

Steph

I've been looking fir over a year.  I had them in an email.  Still trying to figure out where I put them....

Sorry,

Jen
To move forward is to leave behind that which has become dear. It is a call into the wild, into becoming someone currently unknown to us. For most, it is a call too frightening and too challenging to heed. For some, it is a call to be more than we were capable of being, both now and in the future.

Offline flower1221

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Re: How I got FFS Paid for by Insurance
« Reply #125 on: December 02, 2017, 09:55:17 pm »
Great info! Thanks, I have CIGNA OAP in Maryland, anyone have experience with them?

Offline Rachel

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Re: How I got FFS Paid for by Insurance
« Reply #126 on: February 25, 2018, 01:29:03 pm »
Hi Jen,

I received my appeal one denial letter February 2 and I will be filing a second level appeal.

In the second level appeal I will:

1) correct the claim amount. For some reason they are stating the claim is for $42,000 and not $50,000,
2) Define the CPT codes I had performed verses the CPT codes they allow in their CPT code list,
3) I will state that the plan specifically restricts FFS and names the restricted procedures and that Aetna defines them as elective and that I have 2 MD's, LSW head of the Mazzoni Trans program and my SLW state that the procedures are / were medically necessary and as such have been covered for others and denying me care is a discriminatory act.

The second level appeal is in the mail.



« Last Edit: February 25, 2018, 05:07:38 pm by Rachel »
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Offline Stephaniek

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Re: How I got FFS Paid for by Insurance
« Reply #127 on: May 14, 2018, 11:46:44 pm »
Does  any one know of two court cases at all. My insurance blue shield California rejected  me again for third time

Offline V M

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Re: How I got FFS Paid for by Insurance
« Reply #128 on: May 15, 2018, 01:53:38 am »
Hi Stephaniek  :icon_wave:

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Offline AmandaSch

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Re: How I got FFS Paid for by Insurance
« Reply #129 on: May 19, 2018, 10:34:51 pm »
I judt moved to Texas and got a job, maybe one that i dont want, but i believe they have top notch insurance. Although I’m only considered part time i have to wait. But a surgeon here in
the Houston area says that Blue Cross/Blue Shield of Texas will cover breast augmentations
and FFS. So when I’m eligible for the insurance i can see what I can get covered here.

Offline ShadowFox

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Re: How I got FFS Paid for by Insurance
« Reply #130 on: May 27, 2018, 01:14:03 pm »
Hello,

I recently have FFS surgery with Dr. Zukowski, aka Dr. Z. I have BCBS for my insurance as well. Initially I did everything I could think of prior to surgery. I received a letter from a therapist, a doctor, the surgeon and from a mental health evaluation. The pre-certifications went through and everything seemed to be going the right course. I spent about 8 months dealing with insurance, jumping through all their various hoops.

Once I finally received the surgery, I sent through the claim. After extending the processing and losing paperwork constantly, my insurance finally responded.

They approved the claim but have only chose to cover a mere $4,400 from a total bill of $55,500.

Obviously this menial amount is far from acceptable. Plus I'm beginning about to get my next line of body surgery done with Dr. Z. The scenario is mirroring the first. Everything is fine until the surgery, but when I send the claim, it will probably try to only cover a very tiny portion.

I'm in the process of setting up the appeals process right now for the first claim. I will likely need to do the exact same thing again in several months for the next claim.

Would you possibly be able to provide me with any sort of useful/helpful information from your claims process that I may use? It sounds like we have nearly identical circumstances. I could really benefit from any aid at this point.

Offline JLT1

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Re: How I got FFS Paid for by Insurance
« Reply #131 on: July 21, 2018, 07:26:28 pm »
HI,

Some possible help... In your appeal, start with this!  Work with you surgeon as well.

The goal of Facial Feminization Surgery (FFS) in a patient suffering from severe gender dysphoria, is not to look beautiful (the goal of cosmetic surgery) but to look female.  This is a fundamental difference and  Fundamental difference Often, in the hands of a skilled surgeon, the patient looks like a sister, mother or other close relative.  Although the surgical techniques are identified with the same name, the application of the technique is very different and requires physicians/surgeons specifically trained in FFS surgery to achieve quality results. This is accomplished by removing or filling in the distinct facial characteristics of a male skull to make it appear female and is often accompanied by reduction of the Adams Apple. While all differences cannot be changed, if enough are changed, visual cues will result in the patient being identified as female and the goal of FFS is accomplished.  (Stress This!!!!!!!  I can't say this enough!!!!!)

Differences Between the Male and Female Skull: Male and female skulls develop differently due to the influence of testosterone (male) or estrogen (female).  A detailed discussion of the differences between the two sexes was provided by the Smithsonian recently and this discussion follows that guide (Smithsonian's The Secret in the Cellar an educational resource from the Written in Bone exhibition, February 2009 – 2014, accessed  online at https://anthropology.si.edu/writteninbone/comic/activity/Skeleton_male_or_female.htm

The differences between a male and female skull are shown below: Grab the drawings for illustration.  Basically, look at the difference between male and female skulls, and give them the surgical procedure that corrects this difference. 

Skull (Cranium and Mandible)

Male Skulls

Generally larger than female  (Can't Do Anything, no surgical correction)
Larger brow ridges, with sloping, less rounded forehead (facial bone reduction to smooth ridges, possible shaving or smoothing of forehead)
Greater definition of muscle attachment areas on the back of the head (Can't Do Anything, no surgical correction)
Larger projections behind the ears (mastoid processes) (Possible reduction)
Square chin with a more vertical (acute) angle of the jaw (reshaping jaw)
Drawings of male skulls (frontal and side views) with arrows pointing to the chin, the brow ridge, forehead, angle of the chin, mastoid process and muscle attachment area at the back of the head.

Figure 3. Male skulls. (Source: Smithsonian Institution, illustrated by Diana Marques)  (Want the patient to look like this)

Female Skulls

Smoother bone surfaces where muscles attach
Less pronounced brow ridges, with more vertical forehead
Sharp upper margins of the eye orbits (
Smaller projections behind the ears (mastoid processes)
Chin more pointed, with a larger, obtuse angle of the jaw
Drawings of female skulls (frontal and side views) with arrows pointing to the chin, the brow ridge, forehead, angle of the chin, mastoid process and muscle attachment area at the back of the head.

Figure 4. Female skulls. (Source: Smithsonian Institution, illustrated by Diana Marques)

What Do You Think?

Comparing the skull from the cellar in Figure 5 (below) with the illustrated male and female skulls in Figures 3 and 4, check Male or Female to note the sex depicted by each feature.

Frontal and side views of the skull from the cellar.

Figure 5. Skull of the skeleton in the cellar. (Source: Smithsonian Institution)

Drawings of female skulls (frontal and side views) with arrows pointing to the chin, the brow ridge, forehead, angle of the chin, mastoid process and muscle attachment area at the back of the head.

(Note:  I need to find a reference about noses of men vs. women (womens noses are smaller relative to total facial area)....  While not called out in the Smithsonian site, there is a difference between male and female cheekbones (see https://forensicoutreach.com/library/4-ways-to-determine-sex-when-all-you-have-is-a-skull/).  I don't know what to call this.  However, this is why cheek implants may be added to the surgery, depending on the degree of widening below the eye. 

Hugs,

Jen
To move forward is to leave behind that which has become dear. It is a call into the wild, into becoming someone currently unknown to us. For most, it is a call too frightening and too challenging to heed. For some, it is a call to be more than we were capable of being, both now and in the future.

Offline Queenie

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Re: How I got FFS Paid for by Insurance
« Reply #132 on: July 22, 2018, 03:08:57 pm »
Wow this immensely helps. I'll be sure to try and do this. Thank You!

Tags: advice FFS Insurance