Susan's Place Transgender Resources

This was a process: it has been long, sometimes humiliating and often frustrating.  However, even with a discount, the final price for me to have FFS went over $50,000 US.  I found motivation easily.  I also found discouragement and frustration even easier to come by.  I started the process in June of 2013, and got my approval letter March of this year.  Part of the problem was that my employer, who had offered a choice in carriers, cancelled my carrier and went with the cheaper carrier effective January 1, 2014.  As a result, all of the calls, letters, recommendations and endless explanations I had gone through needed to start again.  Then, there was the plan change. 

My new insurance plan stated that they would pay for SRS and with sufficient medical justification, breast augmentation.  Other surgeries, such as tracheal shave and rhinoplasty would be addressed on a case by case basis.  We do know that several of us have transitioned over the past few years with the same low cost carrier and none managed to meet the requirements.  The biggest problem is that they would not tell anyone what was needed; just constant reviews and denials for feedback.  In the end, this was what I needed:

1.  A letter of recommendation from my primary care physician.  The form and requirements of a WPATH recommendation for SRS from a psychologist had to be followed.  In addition, the letter had to address my physical health and any possible undo risks of surgery.

2.  A letter of recommendation from my psychologist, following WPATH SRS standards.

3.  A letter from the surgeon stating what was being done and why as well as a letter under the WPATH guidelines for a psychologist recommending SRS.

4.  A plan, from me, detailing my journey to becoming a woman, including dates for milestones:  When I started with my psychologist, when I started HRT, when I started RLE, when I will be changing my legal name and gender (with court appointment documentation), when I will have SRS (with letter from surgeon documenting date).

5.  The surgeon (Dr. Z) was also kind enough to provide legal references to two court decisions stating that FFS was a medical treatment for GID and not a cosmetic surgery.  Dr Z also provided them with recognized insurance codes for the treatment. (These two items were critical.)

Overall, most of this is needed for SRS, from the surgeon or for the actual transition.  The only additional item was the letter from my primary care physician.  I called and called and finally found someone who worked with me.  She was fantastic.  No, it was not fair.  Now we know, now we can make it easier for those who follow and perhaps, those who have already transitioned.

Hugs,

Jen

Congrats

Jen, this is excellent. And excellent work. Be proud.

Wow Jen, this is amazing!

I'm a bit worried now, you say you're FFS in total would cost 50k, but I would only be able to save around 20-25k and it seems like I won't be able to afford it.

I just have a quick question, my Company's insurance plan explicitly states that "cosmetic surgeries" for trans patients will not be covered, including FFS and breast augmentation.  Was that the same case for you, and you fought to appeal that?

Any info is GREATLY appreciated!

Quote from: amber4400 on March 22, 2014, 02:35:38 PM
Wow Jen, this is amazing!

I'm a bit worried now, you say you're FFS in total would cost 50k, but I would only be able to save around 20-25k and it seems like I won't be able to afford it.

I just have a quick question, my Company's insurance plan explicitly states that "cosmetic surgeries" for trans patients will not be covered, including FFS and breast augmentation.  Was that the same case for you, and you fought to appeal that?

Any info is GREATLY appreciated!

Amber,

Before I get to your answer, please be aware that my avatar is, more or less, what I will look like after FFS.  I currently have serious male features and cannot pass at all. 

The cost of FFS is dependent on the cost of the individual procedures.  I'm essentially having everything done: brow lift, orbital rim bossing, blepharoplasty, cheek augmentation, rhinoplasty, upper lip lift, chin reduction, multi-plane face lift and tracheal shave.  That's a lot of work and everyone doesn't need it.  Figure 3-6K per procedure and then figure out what you need to get at your total cost.

My plan did forbid cosmetic surgery.  It did forbid surgery under transgender coverage surgery to correct old injuries (e.g. septology to correct a broken nose).  It did allow for facial surgery and BA with medical justification.  The key there is that they had never paid a claim because medical justification could not be met.

In your case, it could be even tougher.  You will need to start with the court cases showing that this isn't being done for cosmetic purposes and second, that the insurance codes, recognized throughout the industry, are not for cosmetic surgery.  (I'll post that information Monday, this thread.) You may want to first contact your state's insurance board with your ducks in a row and find a sympathetic ally.  Know the law first.  Have it all together and then go for it.  This isn't cosmetic surgery.   However, you probably don't need it all as I do.  Go only for what you really need and use your money to get whatever else you want.

If you need additional help that cannot be posted on an open forum..  PM me and I'll do what I can.

Good Luck...

Hugs,

Jen

That is amazing that you were able to organize this & actually receive help from an insurance company. My health insurance is with Blue Cross & I'm sure there is no chance for any help with change/correction of gender.

Anyway good for you GF.

Quote from: FrancisAnn on March 22, 2014, 07:31:38 PM
That is amazing that you were able to organize this & actually receive help from an insurance company. My health insurance is with Blue Cross & I'm sure there is no chance for any help with change/correction of gender.

Anyway good for you GF.

My old insurance company was Blue Cross and Blue Shield.  I dealt with them for four months and when my company decided to change, they stopped working with me.  Had we not changed, it would have been approved.  I got them down to just one recomendation left and that was the one from my pimary MD.  I just couldn't meet the time line as my primary is busy. You can do it if your policy covers SRS.

Hugs,

Jen

Thanks on BCBS. I will check into it. I've had coverage with them for 6 years & pay them very well. That would be so nice.

Hi Jen,

There is a lot of confusing and contradicting information on the internet, I don't know if this thread is the right place to ask this question but just curious if you know the answer.  A source of confusion has to do with the HRC equality rights, and corporate index.  According to the Human Rights Campaign, any Company that receives a perfect score has to include transgender health benefits.  Reading the print the HRC provides is VERY vague to say the least, they say each Company needs to meet or exceed $75,000 worth of health benefits, including: SRS, HRT, FFS etc.  This is where it gets very confusing, my Employer is a top ten rated Company by them, and I read my health insurance coverage very thoroughly, and it explicitly states that all FFS, BA, Voice, Hair removal related procedures are all optional and excluded from coverage.  I really don't know where to go from here?

Thank you so much to anyone who can answer this!

Amber: Still working on getting the informaiton.  I should have it tomorrow.  Are there different levels of insurance offered through your company?  Mine has four plans.  What you have said isn't right if they want to keep the rating.  I'll keep looking.

Hugs,

Jen

HRC does not require companies to cover FFS in order to get 100 on the CEI. I know because my company has a score of 100 and the insurance only covers therapy, HRT, labwork, GRS, and some secondary gender traits (breast aug, mastectomy, trachea shave). FFS, VFS, and electro are explicitly listed as not covered. Which sucks because at roughly $50000 it's going to be several years before I can even afford FFS :(

I have signed this petition to HRC so that maybe this will change in the future. (https://www.change.org/petitions/human-rights-campaign-hrc-mandate-the-2016-corporate-equality-index-and-2016-municipal-equality-index-score-of-100-to-include-coverage-of-all-related-transgender-gender-reassignment-procedures)


Jen, I am interested in the legal rulings Dr. Z. gave you concerning these gender reaffirming surgeries to be medically necessary and not cosmetic. I think I'm going to try and make a case with my employer that they should push for our insurance to cover such procedures.

Quote from: JLT1 on March 22, 2014, 08:02:27 PM
My old insurance company was Blue Cross and Blue Shield.  I dealt with them for four months and when my company decided to change, they stopped working with me.  Had we not changed, it would have been approved.  I got them down to just one recomendation left and that was the one from my pimary MD.  I just couldn't meet the time line as my primary is busy. You can do it if your policy covers SRS.

Hugs,

Jen

Im book marking this page for later reference! :D    I have BCBS, what was their response or needs to cover ffs?

EDIT

I did find this from BCBS about covering transgendered persons. Maybe other insurance companies have a page like this.

http://www.bluecrossma.com/common/en_US/medical_policies/189%20Transgender%20Services%20prn.pdf

All....Codes and associated descriptions are below....Hugs,  Jen

CPT    21137   Endoscopic assist 3 dimensional reduction of orbital rim bone and frontal bone via high speed burring   

CPT   14041   Adjacent tissue transfer for scalp advancement

CPT   15824   Rhytidectomy; forehead with elimination of corrugator and procerus muscles

      Primary feminizing rhinoplasty and septoplasty with inferior turbinate infracture   
CPT   30410   Rhinoplasty primary; complete external parts including bony pyramid, lateral and alar cartilages and/or elevation of nasal tip

CPT   30520   Septoplasty with submucous resection

CPT   30930   In-fracture of inferior turbinates
   
      Full feminizing facelift of skin, SMAS plication and corset platysmaplasty with internal     suspension sutures   

CPT   15828   Minimal scar rhytidectomy of lower cheeks, chin and neck   

CPT   15829   Superficial SMAS plication

CPT   15825   Platysmal flap of neck

      Chin feminization with three dimensional bone contouring and reshaping of chin soft tissue   
CPT   21209   Chin bone 3 dimensional endoscopic assist reduction via high speed burring and soft tissue reshaping

      Trachael shave   
CPT   31750   Tracheoplasty, cervical   

CPT   21195   Bilateral reconstruction of mandibular rami and body with bone contouring via endoscopic assisted high speed burring   

CPT   21296-50   Bilateral intraoral reduction of medial masseter muscle   

CPT   40652   Vertical lip lift   

CPT   20926   Harvest of fat tissue grafts fat grafting (50cc) to temples, lips, cheeks, nasolabial folds   
CPT   21270-50   Bilateral cheek implants – malar augmentation with prostethic material (Medpor) and fixation with titanium screws

CPT   11954   Subcutaneous injection of fat in temples, nasolabial folds, lips and cheeks  bilaterally

CPT   19499   Cost of 1 pair Medpor 3mm cheek implants with 2 titanium screws   

Quote from: Kyra553 on April 02, 2014, 10:19:23 PM
Im book marking this page for later reference! :D    I have BCBS, what was their response or needs to cover ffs?

EDIT

I did find this from BCBS about covering transgendered persons. Maybe other insurance companies have a page like this.

http://www.bluecrossma.com/common/en_US/medical_policies/189%20Transgender%20Services%20prn.pdf

Kyre,

None of the codes that are "forbidden" or are listed as not paid for by BC&BS are the ones that are considered medically necessary......

Perhaps you should try.

I think that it just might get covered.

Hugs,

Jen

Quote from: Alaia on March 30, 2014, 07:50:05 AM
Jen, I am interested in the legal rulings Dr. Z. gave you concerning these gender reaffirming surgeries to be medically necessary and not cosmetic. I think I'm going to try and make a case with my employer that they should push for our insurance to cover such procedures.

FFS is not covered?  Read closer, all medically necessary procedures are covered.  See CPT codes above.

Hugs,

Jen

Quote from: amber4400 on March 23, 2014, 11:47:14 PM
Hi Jen,

There is a lot of confusing and contradicting information on the internet, I don't know if this thread is the right place to ask this question but just curious if you know the answer.  A source of confusion has to do with the HRC equality rights, and corporate index.  According to the Human Rights Campaign, any Company that receives a perfect score has to include transgender health benefits.  Reading the print the HRC provides is VERY vague to say the least, they say each Company needs to meet or exceed $75,000 worth of health benefits, including: SRS, HRT, FFS etc.  This is where it gets very confusing, my Employer is a top ten rated Company by them, and I read my health insurance coverage very thoroughly, and it explicitly states that all FFS, BA, Voice, Hair removal related procedures are all optional and excluded from coverage.  I really don't know where to go from here?

Thank you so much to anyone who can answer this!

Try it anyway.  Make them reject the procedures and associated codes.

Hugs,

Jen

Thank you so much for putting this info out there. Unfortunately, it doesn't help me personally, but I know it will be of benefit to others in the community that I can share the info with.

Thanks again
Kelsie

I have Federal Blue Shield Blue Cross. I couldn't find anything in my plan covering SRS or FFS. I will have to look into getting referrals to see if I can get covered. I do plan on working with Dr. Z but I want to wait two years to see what the HRT does to me first.

Thanks for putting this information together!

Quote from: JLT1 on March 21, 2014, 10:51:04 AM
The surgeon (Dr. Z) was also kind enough to provide legal references to two court decisions stating that FFS was a medical treatment for GID and not a cosmetic surgery.  Dr Z also provided them with recognized insurance codes for the treatment. (These two items were critical.)

I know this is an old thread, but hopefully I can get a response anyway. I can't figure out how to send a PM.

Could you provide the names of the two court decisions? I'm trying to get SSI to speed up my back pay and that info certainly wouldn't hurt.

Thx

Quote from: ldzilch on November 22, 2014, 01:40:41 AM
I know this is an old thread, but hopefully I can get a response anyway. I can't figure out how to send a PM.

Could you provide the names of the two court decisions? I'm trying to get SSI to speed up my back pay and that info certainly wouldn't hurt.

Thx

Hi,

You can't send a PM until you get enough posts (15??).  I won't have time to look through everything until tomorrow night - I'm at work right now..... :(.  For now, use this tread as your PM system.  I check for new responses every couple of days so we can get you started with help. 

Hugs,

Jen

Hi Jen, you look beautiful

I have Aetna and FFS is excluded or so I was told and provided in writing. Many procedures are covered but not FFS. I am wondering if I should pursue it? Our company is self insuring most of the trans procedures where Aetna falls short. 

I would do FFS prior to GRS but the cost out of pocket excludes me.

Cynthia,

Exactly, word for word, what does your policy state?  With that information we can then start working on it.

You may have to show medical necessity.  I can help you do that as well.

So, find your policy and send that quote. 

Hugs,

Jen

Thank you Jen,

I just put in a request to Aetna for a PDF for MTF transsexual covered and excluded benefits. I was sent earlier by my work benefits department what procedures were covered and excluded but not the text,

thank you, for the help and providing hope, Hugs Cynthia.

Cynthia,
I too have aetna insurance and would love it if you can share what procedures are excluded.   
thanks

Hi Jen,

You wouldn't happen to know the codes for SRS would you just in case I need them? My insurance says they do cover it but it never hurts to be prepared.

Thanks for posting those for FFS tho I dunno if I'll need any procedures. For FFS I intend to wait the full 2 to 3 years on hormones and then see if/what procedures I might need. My SRS tho will be sometime this spring so it's a pressing issue.

Thanks in advance. :icon_bunch:

Ally :icon_flower:

Quote from: Allyda on November 26, 2014, 01:13:33 AM
Hi Jen,

You wouldn't happen to know the codes for SRS would you just in case

Ally :icon_flower:

I'll PM the to you.  I found those  Still looking to for the court case information.

Hugs

Jen

Hello Jen

Fist off, thank you so much for the help and information provided. I am in the process of getting my SRS and FFS as many of us had mentioned, SRS is covered by my Insurance company that happens to be United Healthcare. I believe I can fight them to actually covered a few of the FFS procedures I wanted to have done... I would like to ask you for your help and mentor me in how to proceed. I have the documents of what is cover in my policy. Since I am new to the forum I can send PM given the restrictions of the site, i wanted to ask you if you were able to find he court cases information?
I have a letter from a PhD stating my medical necessity for SRS but we can change the wording following the WPATH code of care for transgender people stating that not only SRS is medically necessary but also facial feminization procedures. I just wanted to have some more info to based my petition, for example those court cases... and the procedure codes you listed are very useful as well!

Hope you can guide me in the right direction.

Thanks a lot Jen and Happy thanksgiving to you all!!! 

So you got FFS back in may right?  So it's been about 6 months?

When is your profile picture from?  Have you noticed any changes since then?

I have a really high forehead and I wonder if anything can be done about it.  I worry the bone might be too thin but I have no idea...

Quote from: gslvqz on November 26, 2014, 01:53:21 PM
Hello Jen

Fist off, thank you so much for the help and information provided. I am in the process of getting my SRS and FFS as many of us had mentioned, SRS is covered by my Insurance company that happens to be United Healthcare. I believe I can fight them to actually covered a few of the FFS procedures I wanted to have done... I would like to ask you for your help and mentor me in how to proceed. I have the documents of what is cover in my policy. Since I am new to the forum I can send PM given the restrictions of the site, i wanted to ask you if you were able to find he court cases information?
I have a letter from a PhD stating my medical necessity for SRS but we can change the wording following the WPATH code of care for transgender people stating that not only SRS is medically necessary but also facial feminization procedures. I just wanted to have some more info to based my petition, for example those court cases... and the procedure codes you listed are very useful as well!

Hope you can guide me in the right direction.

Thanks a lot Jen and Happy thanksgiving to you all!!!

I'll have time Saturday night to get everything together.   I found some more. ..  I know it's doable.

Lemons,   check our the before and after thread on page 8 for more recent pictures.   You won't be to thin


Hugs

Jen

Quote from: JLT1 on November 27, 2014, 01:56:40 PM
I'll have time Saturday night to get everything together.   I found some more. ..  I know it's doable.

Lemons,   check our the before and after thread on page 8 for more recent pictures.   You won't be to thin


Hugs

Jen

Wow, thanks a lot for being so prompt to reply. I really appreciate it. 
I am really sorry that I did not introduce myself. I was so excited when I was reading at your comments and replies on the forum that I totally forgot about it. But let me properly introduce myself, my name is Giselle, I live in sunny Az. it is a pleasure to meet you!
I hope you had a wonderful Thanksgiving.

Once again, I want to thank you for all your help, please know that it is very appreciate it not only for me but from what I have read for many other members whom are truly interested in getting their procedures through their insurance company.

You take care and enjoy the weekend.

Best,
Giselle

I requested the written insurance document from Aetna. They referred me to my work Benefits department. I left a message for the Sr. Benefits Manager then Friday I sent a very specific e-mail ( She was out for the holiday). I am hoping to get the written document without too much trouble. I have the chart with Medical terms and what is covered / not covered from Aetna ( I have Aetna POSII) as-well-as my work ( work covers some procedures above what Aetna covers). When I have everything I will ask how to send or post the information.

Ali, if you pm your contact information I will send you the chart. Or perhaps let me know how to post it here.

Insurance codes and costs used that covered my FFS:

ICD9         302.85   Endoscopic biplaner browlift with frontal bone and supraorbital bone burring with corrugator and procerus muscle disruption scalp advancement
   
CPT    21137   Endoscopic assist 3 dimensional reduction of orbital rim bone and frontal bone via high speed burring   $7,000.00
CPT   14041   Adjacent tissue transfer for scalp advancement   3,000.00
CPT   15824   Rhytidectomy; forehead with elimination of corrugator and procerus muscles   2,500.00
      
Primary feminizing rhinoplasty and septoplasty with inferior turbinate infracture   
CPT   30410   Rhinoplasty primary; complete external parts including bony pyramid, lateral and alar cartilages and/or elevation of nasal tip    7,000.00
CPT   30520   Septoplasty with submucous resection   2,000.00
CPT   30930   In-fracture of inferior turbinates   2,000.00
      
Full feminizing facelift of skin, SMAS plication and corset platysmaplasty with internal suspension sutures
   
CPT   15828   Minimal scar rhytidectomy of lower cheeks, chin and neck   7,500.00
CPT   15829   Superficial SMAS plication   2,000.00
CPT   15825   Platysmal flap of neck   4,000.00

      
Chin feminization with three dimensional bone contouring and reshaping of chin soft tissue
   
CPT   21209   Chin bone 3 dimensional endoscopic assist reduction via high speed burring and soft tissue reshaping   4,500.00
      Trachael shave   
CPT   31750   Tracheoplasty, cervical   5,000.00
CPT   21195   Bilateral reconstruction of mandibular rami and body with bone contouring via endoscopic assisted high speed burring   7,500.00
CPT   21296-50   Bilateral intraoral reduction of medial masseter muscle   3,000.00
CPT   40652   Vertical lip lift   3,800.00
CPT   20926   Harvest of fat tissue grafts fat grafting (50cc) to temples, lips, cheeks, nasolabial folds   1,250.00


That's it for the codes.  Note that they justified the procedure in terms of feminization prior to code

Hugs,

Jen

The relevant section from my "WPATH Justification Letter":

...........in many ways, this gender problem is a nightmare and a condition I would not wish on my worst enemy. However, it is what it is and I am doing the best that I can.  Under the relevant World Professional Association for Transgender Health (WPATH) Standards of Care for Gender Identity Disorder, the surgery is considered medically necessary:

"Medically necessary sex reassignment procedures also include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient (including breast prostheses if necessary), genital reconstruction (by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, penile and testicular prostheses, as necessary), facial hair removal, and certain facial plastic reconstruction as appropriate to the patient.

Non-genital surgical procedures are routinely performed... notably, subcutaneous mastectomy in female-to-male transsexuals, and facial feminization surgery, and/or breast augmentation in male-to-female transsexuals. These surgical interventions are often of greater practical significance in the patient's daily life than reconstruction of the genitals.   Furthermore, not every patient will have a medical need for identical procedures; clinically appropriate treatments must be determined on an individualized basis with the patient's physician.

The medical procedures attendant to sex reassignment are not "cosmetic" or "elective" or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition."  WPATH Medical Necessity Statement, June 17, 2008

The surgery is medically necessary as part of the indicated treatment for Gender Identity Disorder........ 

Jen

Example of an insurance appeal letter....

"My Address and Insurance Information


                  My Insurance Company Address

Date

RE: Appeal of Coverage Decision regarding the Co-Pay Amount, Expedited Determination or Fast Coverage Decision requested

To Whom it May Concern:

Please consider this fax to be a request for an expedited determination of the appropriate benefit level coverage (out of network 55% benefit level approved, 90% benefit level requested) for all procedures referenced in Attachment A "Precertification letter from Dr Mark L. Zukowski for facial feminization surgery".  All procedures requested were either covered without precertification or were approved under Authorization # 35511881 (Attachment B). 

The request is for facial feminization surgery (FFS) under the "gender reassignment surgery" coverage criteria was supported by Dr XXXXXX, Psych Ph.D. XXXXXX and Endo XXXXXX (all in-network Providers).  All other requirements for the surgery were met as well.  FFS is a unique area of practice whereby the surgeon alters male facial features to bring them closer in shape and size to typical female facial features.  For many transgendered women, FFS is medically necessary to treat gender dysphoria and can be just as important, if not more important than genital surgery.1,2   

Quoting from the letter from Dr Zukowski (Attachment A) "As you know, these codes are the best match for what is required for the feminizing part of the operation." The codes are "best match".  Codes specific to FFS are not available.  However, no doctor within the Health Partners Network offers FFS although they may provide service covered under a certain code. Therefore, this letter requests that the in network coverage level be extended to all Dr. Zukowski's procedures.




                  Sincerely,


                  Me
 
Sent Via Fax on date to XXX-XXX-XXXXX

1.  World Professional Association for Transgender Health. WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A. (2008).
2.  World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, Version 7.

HI,

I can't find the fax with the two court rulings.  However, I did find one while searching...

http://law.justia.com/cases/new-york/other-courts/2014/2014-ny-slip-op-24078-0.html

Legal defense fund won one for employee leave...

http://www.advocate.com/news/daily-news/2011/11/16/woman-allowed-medical-leave-facial-ferminization-surgery

IRS Affirms that transition related medical expenses are deductible.....

http://transgenderequality.wordpress.com/2012/01/06/irs-affirms-that-transition-related-care-is-tax-deductible/

Jen

Quote from: Cynthia Michelle on November 29, 2014, 01:22:37 PM
I requested the written insurance document from Aetna. They referred me to my work Benefits department. I left a message for the Sr. Benefits Manager then Friday I sent a very specific e-mail ( She was out for the holiday). I am hoping to get the written document without too much trouble. I have the chart with Medical terms and what is covered / not covered from Aetna ( I have Aetna POSII) as-well-as my work ( work covers some procedures above what Aetna covers). When I have everything I will ask how to send or post the information.

Ali, if you pm your contact information I will send you the chart. Or perhaps let me know how to post it here.

Hey,

The general considerations on Transgender surgery from Aetna are found at: http://www.aetna.com/cpb/medical/data/600_699/0615.html

Note that they keep referencing WPATH as the standard they follow and yet they ignore that WPATH recognizes the necessity of FFS.  It's going to be hard.  You have to establish medical necessity for you (letters from your psych, GP and endo will do) and to establish that they cover "cosmetic procedures" in the case of trauma.  Once you do both of those, it's two appeals to the insurance company and an appeal to you state's insurance board.  You should win on that appeal.

I did all my own appeals.

Hugs,

Jen

JLT, thank you so much, hugs.

I have work to do :)

You look so good I definitely will do this :)

I never went to this section because of the insurance exclusion. Then for some reason I went here and saw you post. Now I have hope.

Quote from: JLT1 on November 29, 2014, 05:31:18 PM
Hey,

The general considerations on Transgender surgery from Aetna are found at: http://www.aetna.com/cpb/medical/data/600_699/0615.html

Note that they keep referencing WPATH as the standard they follow and yet they ignore that WPATH recognizes the necessity of FFS.  It's going to be hard.  You have to establish medical necessity for you (letters from your psych, GP and endo will do) and to establish that they cover "cosmetic procedures" in the case of trauma.  Once you do both of those, it's two appeals to the insurance company and an appeal to you state's insurance board.  You should win on that appeal.

I did all my own appeals.

Hugs,

Jen

Hello Jen,

You are mentioning something very true, they say they follow the WPATH standard but in the case of United Healthcare they do the same thing, they consider FFS as cosmetic.
This is the link for all of you who have United HealthCare as your Insurance Administrator that consider the care for Gender Identity Disorder.  (At the bottom of my message)
It does cover hormones and SRS and even breast implants if needed for those companies policy that covers SRS, which it is my case. I am with GE (General Electric), hoping this company being one of the biggest in the world could provide me with FFS!! I have heard the United Healthcare is very stubborn and cookie cutter like when it comes to coverage.. so I will need to fight against it the best I can.

Thank you so much Jen for all the comprehensive information...

I do have another question or recommendation to ask.. Do you think it is best to go see Dr. Z previous to send letter asking for coverage or should I visit Dr Z and let him send the pre approval request? How did you do it? You send the claim and appeal the denial from your insurance or did you have a consultation with Dr Z and then proceed with the recommendation made by him? did you send the letter and pre approval request or did he did it for you?

I know that for my SRS, I would just send everything to Dr. Bowers and she would work with United Healthcare until we scheduled a date for my SRS, basically they take care of everything but in this case since I know that the claim will be declined, how should I proceed?

If you could advise me on this, I would really appreciate it

Hugs and best wishes,

Giselle

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Gender_Identity_Disorder_CD.pdf (https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Gender_Identity_Disorder_CD.pdf)

HI,

Quick note an then we will get serious tomorrow night....

Check your exact policy.  I work for 3M.  I eleive you have multiple plans like we do.  Check your exact plan because the document you sent says "Certain plans may have a different list of exclusions. Check the plan-specific documents before making a determination."  Get the exact one.

I aam sure we can get partial coverage.  Don't know about full. 

Hugs,

Jen

Good morning Jen,

Yes, mine does cover Sex Re-Assignment Surgery. I am under one plan called Health Choice, my deductible is 800 and my max out of pocket is 1300. So it is a very generous policy. I have read the whole document and it says that after those 1,300, everything... any surgery or medical cost os paid 100% by GE. The document also (under 'What is covered') states that:

1.6.15 GENDER RE-ASSIGNMENT
Gender reassignment includes sexual reassignment surgery, mastectomy/chest reconstruction surgery, behavioral health therapy and hormone therapy as determined by the Claims Administrator in accordance with the World Professional Association for Transgender Health (WPATH) standards of care. You must be age 18 or older, have persistent gender dysphoria and the capacity to make a fully informed decision. Limited to one re-assignment per lifetime.

I just realized that that paragraph found in the document given to us as employees for the right benefits guide, states 'as determined by the Claims Administrator (which it is United Healthcare) but also mentioned IN ACCORDANCE WITH the WPATH standard of care... maybe I could win!!

In the Health Benefits guide only mentions this because then they refer you the Claims Administrator Document for more details... which it is the one I posted the link.
I can't actually post the Health Benefits guide because it is only visible through Intranet and not allowed to be copied, they have it locked! .. only printed.  :(

Thank you Jen  :)

Have a wonderful beginning of the week!

I'm on UHC, same as Giselle. My SPD clearly states that GRS and specified secondary sex characteristics are covered (breast aug, trachea shave, and mastectomy for FtMs). FFS and VFS are listed in the exclusions section. I Find it interesting though that the document Giselle linked states the following:

QuoteThe treatment plan must conform to the World Professional Association for Transgender
Health Association (WPATH) standards (WPATH 7th edition)*;

This could leave an opening to contest FFS coverage as WPATH v7 standards have a medical necessity statement (http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1352&pk_association_webpage=3947):

QuoteMedically necessary sex reassignment procedures also include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient (including breast prostheses if necessary), genital reconstruction (by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, penile and testicular prostheses, as necessary), facial hair removal, and certain facial plastic reconstruction as appropriate to the patient.

"Non-genital surgical procedures are routinely performed... notably, subcutaneous mastectomy in female-to-male transsexuals, and facial feminization surgery, and/or breast augmentation in male-to-female transsexuals. These surgical interventions are often of greater practical significance in the patient's daily life than reconstruction of the genitals."  [3]

Furthermore, not every patient will have a medical need for identical procedures; clinically appropriate treatments must be determined on an individualized basis with the patient's physician.

The medical procedures attendant to sex reassignment are not "cosmetic" or "elective" or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.

So WPATH has made it very clear, and I would think any policy stating that treatment must follow WPATH v7 standards has then left an opening for FFS coverage. Even if you fight it and they don't though, Jen made a good point about multiple policies being available. Some of the other plans offered may have verbiage that allows for more wiggle room. I've currently raised the question with my HR/Benefits dept about whether FFS is covered since we state we are following WPATH v7 standards. Still waiting to hear back on that but I will let you know how it goes.

-Alaia

Quote from: Alaia on December 01, 2014, 03:14:07 PM

This could leave an opening to contest FFS coverage as WPATH v7 standards have a medical necessity statement (http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1352&pk_association_webpage=3947):


So WPATH has made it very clear, and I would think any policy stating that treatment must follow WPATH v7 standards has then left an opening for FFS coverage. Even if you fight it and they don't though, Jen made a good point about multiple policies being available. Some of the other plans offered may have verbiage that allows for more wiggle room. I've currently raised the question with my HR/Benefits dept about whether FFS is covered since we state we are following WPATH v7 standards. Still waiting to hear back on that but I will let you know how it goes.

-Alaia

Hi Alaia,

Good to know you are also dealing with UHC... I have been told they are very tough when it comes to claims being denied if the doc states it is not covered. It seem you and I are under the same coverage... mine mentions Tracheal shave, breast augmentation are covered if medically necessary. But FFS is not since it is considered cosmetic... however the document states they follow the Version 7 of the WPATH standards. And as you mentioned V7 has a medically necessary statement. I think it is very much worth the fight... they are contradicting themselves. And we are in a better position by having the medically necessary statement on the WPATH that they claim are following.

In my case, HR is not the one to contact... they have a department called Health Coach and they are the one who tell you if you are cover or not.. but basically, in my case I do not need any referral to visit a specialist or physician at all.. so I am free to go with whoever I want as long as they are In-network, in my case Dr. Bowers is in-network. I live in AZ so Dr. Meltzer would have been my choice but he is Out of network and I would have to pay more out of pocket when with Bowers I do not pay anything after those 1,800 dlls max out of pocket.

I could actually fight them to get Dr. Meltzer since they also have a statement in my policy that it says that if they cannot find an in-network specialist in my area, they could provide care with a out-of-network dr at the same coverage level of an in-network one. Only thing is that I have seen Dr. Bowers work but I have not seen any from Dr. Meltzer.

Are you ready for SRS yourself, Alaia? or only FFS for now? if so, who would you prefer?

Hope HR gives you the green light to move forward with your FFS!!!

Let's keep each other posted.

Hugs,

Giselle

I wonder how this would work for someone who transitioned 30 years ago?  There was no FFS when I transitioned.

I work for a large employer who self insures, but uses several different insurance companies to administer.  In the state I live in we have either UHC or BCBS.  Only way to find out is for me to contact them.

I have Aetna POS II. I spoke to the person ho handles Trans* claims. He is relatively new and the person he replaced gave him a full breakdown of all those who have had procedures where I work (20,000 employer). There were two others who have procedures (we have had trans* coverage for 1 year). I asked if they cover FFS and he said no. I asked if he knows if Aetna has paid for anyone who has had FFS and he said no.

He provide me the same link Jen proved me which has the written test explaining all the requirements to access coverage paid for by Aetna.

There are a lot of procedures my employer coverers and Aetna is a pass through such as vocal cord shortening, HRT, BA, hair removal, head hair restoration, adams apple shave and therapy.

There is a term he clarified. Which is within 3 years of gender role change for all the Aetna procedures. He said that plus 3 years or minus 3 years of GRS. So basically I need my letters or access Aetna procedures. My work procedures are on demand.

I am working on hair removal so that is a direct pass through for coverage. Now I will add head hair restoration. Also, I will start the process for the FFS battle. Upon FFS I will then proceed with the remainder.

Where I work it is 90% plus female and we have a female president. The vast majority have advanced degrees in medicine and science. Hopefully I will have  understanding co-workers at work.

Hi Jen,
As far as I know my insurance does not cover FFS, I have Mass Health.
When I move to the west coast I will likely be getting new insurance there. (Portland, OR likely)  Wondering if I would have to get on an insurance plan through a job or just apply to find one that can cover FFS.
Thanks!

I have a matrix of what Aetna POS II covers in PDF but I can not figure out how to post it. I can send it to you if you want it, just pm me with your e-mail address and I will send it to you.

Thanks for the awesome thread and great info!


Does anyone happen to know if there is an insurance company out there that offers an independent policy that someone can purchase in NC that might could cover this or at least srs? Thanks!

Quote from: Cynthia Michelle on December 06, 2014, 08:17:46 PM
I have a matrix of what Aetna POS II covers in PDF but I can not figure out how to post it. I can send it to you if you want it, just pm me with your e-mail address and I will send it to you.

Sent

Hello Jen,

How have you been?

Just a quick update in regards of my FFS claim plan with UHC. I have spoken to both GE Capital people who assist with medical claims and also with UHC in regards of getting my FFS and SRS with Dr. Toby Meltzer since I live in the Phoenix area and it would be a lot easier for me than to go with Dr Marci Bowers all the way in CA. Since Dr. Bowers is actually an in-network provider they would work with her in regards of SRS and Tracheal Shave since those are the only two procedures she performs and I was told that if I want Dr. Meltzer to be my surgeon the very first thing I need to do is to submit a Clinical GAP Exception Claim so he can be covered as he was an in-network provider because it is actually an out-of-network physician. I have been in touch with Dr. Meltzer office and they are not being very supportive. A lady called Piper whom I set up my Appointment with told me right off the bat that they do not work with insurance for the GAP exception that that is something I have to do myself. And then I called UHC and they told me the Dr is the one to do it. So I then called my claim specialist with GE Capital and they said it can be done by myself or by the doctor office but it is always best to do it through the Dr office since UHC will request the procedure codes for SRS and FFS. But Dr., well not him but his office do not want to provide me with that info!!  :( 

Do you happened to have the codes for SRS? I found one that is stated in the UHC document 55970 -  Intersex surgery; male to female  but I think that one is too broad.

Did you first have a consultation with Dr. Z in person to discuss the insurance claims you pursued or you did everything on your own and visit Dr. Z when it was already approved?

I would really appreciate your thought about my situation...

Hope you are having a wonderful weekend.

Giselle

Hey Giselle,

So did UHC say they would cover FFS for you? I just heard back from my HR/Benefits contact and they said it isn't covered, that we are still basically on WPATH v6. I've tried going directly to UHC before and they said it wasn't covered also. So if you've heard anything different I'd like to know. Maybe I'm just not talking to the right people.

As for GRS, I was considering going to Dr. Meltzer too, but if he's making it difficult to do the GAP claim then maybe I'll go with Dr. Bowers. She does have great results and it's only another 100 miles further for me to see her instead. Not that it's something I need to urgently think about. I still have to do 12 months full time before insurance covers it. And that clock won't start running until I go FT at work in Jan or Feb.

Hello Alaia,

I was able to give a call to UHC about the GAP exception, they have told me it could be submitted by me if Dr. was not willing to help, but they made a great point, this representative told me, that if the office surgeon was not happy to help me to get this submitted through them maybe that surgeon was not that supportive in providing his services neither. It made me think, I believe a surgeon (or in this case his office) should always be prompt to help patients to make the whole process easy, they will not be making a couple of dlls but a substancial amount for their services, so it should be in their best interest to provide that support to people who is willing to have surgery with them. I don't know, I am a customer oriented business woman and  I always try to put customer's need first so I can provide the best service I could. But not every business think the same way. Good thing is that he is not the only surgeon available. Marci Bowers office on the other hand, it only took me a few mins to let them know my situation and they were truly helpful and took the responsibility on them to look for the most coverage possible and even fight with UHC to make sure I get the coverage I should. A totally perspective in business terms. I felt appreciated as a potential patient that I do not have any doubt I would go with Dr. Bowers for my surgery.

I will still meet with Dr. Meltzer for consultation since they already charged me $100 dlls for the appointment even if the sooner he can see me was March 2nd.

In regards of the medical coverage, I am good with SRS, tracheal shave and breast augmentation with UHC (it is totally covered as long as you meet the criteria), what it is listed as exclusions are the FFS procedures, but in my case they are considering WPATH Standards of Care V.7 so I could fight against UHC for them to provide coverage. I am putting together a good case with court cases and lots of proof of the medical necessity for FFS. As Jen did, hopefully I will win. Still having my doubts is Dr Z is the one I would like to consider for FFS because I have been noticed that he is kind of conservative with Type III procedure. I really want a totally flat and rounded forehead, as the one Dr. DiMaggio in Argentina can provide, but since he is not in America he cannot be considered for UHC coverage by any mean.

Hope you all have a wonderful weekend!

Giselle

Hey Giselle,

Yeah, I think that's the best route for me to take as well. Asking my HR/Benefits dept. was just a dead end. We have the same UHC policy, so I think as long as UHC is claiming to follow WPATH SOC v7 then they should cover FFS. It's not right that in one breath they claim to follow the current standards but then in another they say certain things that would be covered under those standards are instead excluded.

Hi Cynthia,

Please pardon me if i'm replying back incorrectly. As, i'm a young TS and first time replying to a conversation with this website. Please excuse me in advanced!!!

Anyway, I work for a progressive company and I have Medical and Dental insurance via Premera Blue Cross Blue Shield. My company specifically has "Transgender Services " benefits within my plan. As long as the provider abides by the WPATH org. Standards of Care it is covered under my plan (with no maximum lifetime amount).

I have called a couple different providers all over the US and they have no idea that insurances are even going to pay. So, I have to explain and they still are unsure and unaware of this new insurance policy. How should I go about proceeding forward? Any recommendations on a certain provider that knows about insurance benefits?

How do I show medical necessity? Also, a doctor is willing to work with me but she said she doesn't even know how to bill the insurance company because there isn't a specific Transgender/ Transsexual  "CPT or CT code"  they can bill it for. Hmmm, i'm so confused.

Any suggestions moving forward would be a tremendous help!


Ps. Im looking to get FFS, trachael shave, breast aug. and lastly SRS.

:) :) :) :) :) :) :) :) :) :) :) :) :) :) :angel:

Quote from: JLT1 on November 23, 2014, 06:20:38 PM
Cynthia,

Exactly, word for word, what does your policy state?  With that information we can then start working on it.

You may have to show medical necessity.  I can help you do that as well.

So, find your policy and send that quote. 

Hugs,

Jen

Quote from: JLT1 on November 26, 2014, 07:50:47 AM
I'll PM the to you.  I found those  Still looking to for the court case information.

Hugs

Jen

Hey Jen,

You're so informative! My insurance has transgender service benefits. Can I also get the billing code for this surgery so I can give it to my provider as well!? Thanks!! <3 


:D

Thanks for collecting all of this!

I would also really appreciate receiving the insurance related information.  I currently have Aetna, but the university I'm a part of seems to negotiate the insurance for each academic year, so it can change year to year.

JLT, I love all of the information you've posted here. Though, if possible, I would love further coaching on the process you went through for this. This is definitely something I would like to pursue.

The two avenues of approach I have are the VA and Oregon Health Plan. OHP covers SRS, so that's great, but being a student of low-income and means has me taking out student loans in hopes of eventually saving up enough to get a decent FFS job done.  FFS is the largest barrier I have right now to ending my dysphoria and it's the goal furthest out of reach. Until recently, I hadn't even had the drive to try going full time as a result.

Soo....TL;DR....please teach me your magical ways.

Hi Everyone,

To get my FFS covered, I needed letters from my primary care doc, two psychologists, the surgeon and my endo.  I also needed a plan for my transition which included dates for things like, coming out, real life experience, name change and GRS.  Then, I got the letter from the FFS surgeon with the codes.  I sent that all in with copies of the WAPTH text related to FFS.  With all of that AND a lot of phone calls, I got preapproval for FFS coverage.  It took time and effort but it worked.

Last Sept. I had two denials from my insurance for hair removal.  They stated it wasn't covered.  I won on appeal....

Every insurance policy has an appeal process if you dispute claims that are rejected.  This includes preauthorizations.   If one does all the above and the insurance company denies preapproval, you have the right to appeal the decision.   For most policies, there are two appeals to the insurance company – one via mail (or email) and the other in person.  If you lose those two, you can appeal to the state insurance board (or equivalent).  That appeal is in person and the state can order the insurance company to pay (or cover).  I cannot imagine that an insurance policy that clearly states that it follows WPATH standards would not cover FFS if the reasons were clear and if the patient had all the documentation.   

Has anyone ever gone through the entire appeal WITH all the documentation I listed in the first paragraph? 

Jen

Omg I hope Jill or anyone here that is an expert can answer, which surgeons for FFS accept insurance as a payment, and will be willing to write a letter, etc... Dr Z right? Anyone else?

WOW . . . .  Thats really great, I had to fight with medi-cal just to get HRT After 3 yrs of RLE, This was however in 2010.
I am so happy for you!, Good work, seems even today you just gotta wear em down ?
Thank you for your hope  :angel: Clear

I'm curious which BCBS carrier you have. I have the Federal BCBS and it specifically says in their benefits handbook that transgender surgeries and related procedures are not covered.

Jen!

Thank you so much. All this information is a treasure trove of resources. I currently have Kaiser and they do offer TG services--I am using them for HRT (and SRS eventually)--but BA and FFS might be on my list as well.

I was wondering who you would call to initiate these claims--I suppose there's a specific job titled-person to talk to about all of this first and foremost at Kaiser that I should request to speak with? I tried calling and just got sent from one line to the other.

I think I'll take the time now to collect all the proper documentation to see if I can get all of this covered.

Again, thanks so much :)

Audree

Hi,

You have to start with a pre-authorisation.  That is initiated by the Dr's office staff.  Then comes the documentation and the work for you. 

If you have problems, PM me

Hugs

Jen

Quote from: Pinkkatie on September 25, 2015, 06:40:48 AM
I'm curious which BCBS carrier you have. I have the Federal BCBS and it specifically says in their benefits handbook that transgender surgeries and related procedures are not covered.

Do they cover HRT or mention that they follow WPATH?

Jen

Quote from: JLT1 on October 01, 2015, 02:38:49 PM
Do they cover HRT or mention that they follow WPATH?

Jen

It doesn't mention that they follow WPATH. They are covering HRT for me.

Hey JLT1, I would PM you but I don't think I'm able to yet as my account is new. Thank you so much for this information. It literally could be life changing for me.

Okay so, I've been looking over my plan's exact guidelines on GRS, which specifically excludes basically everything other than GRS itself (FFS, BA, tracheal shave, etc) under the pretense of them being "cosmetic". They do mention they follow WPATH guidelines (in the 'References' section, it explicitly references the WPATH SOC v7):

QuoteTranswomen strive for a female identity. Gender reassignment surgery from male to female (MTF) includes procedures that shape a male body into the appearance of and, to the maximum extent possible, the function of a female body. Procedures often performed as part of gender reassignment surgery of MTF according to WPATH SOC include orchiectomy, vaginoplasty, penectomy, and labiaplasty.  Surgical techniques vary but may include penile inversion to create a vagina and clitoris or creation of a vagina from the sigmoid colon (i.e., colovaginoplasty). The objectives of vaginoplasty include improved sexual sensation and function and appearance. Breast augmentation may be considered when 18 months of hormone treatment fails to result in breast enlargement that is sufficient for the individual's comfort in the female gender role.

In the same section that excludes FFS and such, it refers to another guideline about "Cosmetic surgery vs. reconstructive surgery." Upon review of that guideline, I found this:

QuotePsychiatric indications do not warrant payment for cosmetic surgery when no functional impairment is present. However, severe psychological impairment, appropriately documented, can be classified as "significant functional impairment" on an individual consideration basis.

In cases involving psychiatric disorder or involutional changes due to aging, the claim should be accompanied by a report from a psychiatrist who indicates a definite psychiatric condition relevant to the condition to be corrected by the surgery and that the proposed correction is likely to be of significant help in treating the psychiatric problem. These services require medical review prior to payment.

Using this information do you think I have a case for FFS coverage if I could prove that it causes severe psychological impairment/that the proposed correction (FFS) is likely to be of significant help in treating my gender dysphoria?

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Quote from: Madithias on October 07, 2015, 02:40:05 PM
Hey JLT1, I would PM you but I don't think I'm able to yet as my account is new. Thank you so much for this information. It literally could be life changing for me.

Okay so, I've been looking over my plan's exact guidelines on GRS, which specifically excludes basically everything other than GRS itself (FFS, BA, tracheal shave, etc) under the pretense of them being "cosmetic". They do mention they follow WPATH guidelines (in the 'References' section, it explicitly references the WPATH SOC v7):

In the same section that excludes FFS and such, it refers to another guideline about "Cosmetic surgery vs. reconstructive surgery." Upon review of that guideline, I found this:

Using this information do you think I have a case for FFS coverage if I could prove that it causes severe psychological impairment/that the proposed correction (FFS) is likely to be of significant help in treating my gender dysphoria?

Hi Madithias,

Basically, if you put in your time with HRT, some RLE (name change would fix it), and have the plan, letters from two psychologists should get you there. The letters should include some of the language around FFS that is in the WPATH standards.

Essentially, the insurance company is restating the standards.  You may have to appeal and show up in person. 

Good.luck and welcome to Susan's!!

Hugs

Jen

Quote from: Pinkkatie on October 07, 2015, 08:07:03 AM
It doesn't mention that they follow WPATH. They are covering HRT for me.

Your policy could be a little bit tougher.  You can try to do all that I have suggested for the other policy types.  Then make them reject your claim.  At that point, you appeal to the company  and then to the state.  Your psychologist letters need to clearly state the distress and how FFS could solve that distress.  The letters are one key.  Your presentation to the state is another. 

If it gets that far, I can help...

Hugs

Jen

hello all, I am new here.  I have been trying to do some research on insurance covering FFS as a girl i know from massachusetts told me she had private insurance from bcbs- harvard pilgrim and it covered her FFS with Dr Spiegel- whos actually my #1 choice.   I previously for several years had either BCBS or UHC but not in mass.  I wish I had known BA and trach shave were covered as I would have saved 10k but I didn't :(


Anyway.  I left my regular m-f job in july to do travel work to try to save as much as I could as I was really hoping to have FFS in early December.  It's now October and I cannot foresee how I can have 28,000 by December so that is how I ended up where I am now.


Are you or anyone else familiar with this insurance in Massachusetts?   I would be willing to go there to do travel work and purchase this private insurance if it means it'll cover my FFS. 

I'm curious as to how to find out about this insurance and how to go about purchasing it- as I don't see any options online nor have I been able to find any info saying it does or doesn't cover FFS.  Also I'm curious as to if I have to have that insurance a certain amount of time or live there a certain amount of time before it's covered.  Please help with lots of love xo

Quote from: sfbarbie on October 08, 2015, 12:44:49 AM

I'm curious as to how to find out about this insurance and how to go about purchasing it- as I don't see any options online nor have I been able to find any info saying it does or doesn't cover FFS.  Also I'm curious as to if I have to have that insurance a certain amount of time or live there a certain amount of time before it's covered.  Please help with lots of love xo

Hi,

It's the policy that one gets not necessarily where one gets the policy. In the end, most will pay, it's just a lot harder.

What does your current plan say and what other policies are available where you work?

Welcome to Susan's...

Jen

Hi Jenn, I just discovered this thread of information about insurance coverage. First I wanted to thank you for being so helpful it's people like you that bring positivity to transgender communities. My name is Natalia I'm 20 from NY. I am passable most of time but unfortunately still need a few things done to be passable all the time and live a normal life. I am actually in the process to begin my process for Aetna to approve FFS. I'm alittle lost on what to do first. The good thing is I know what they need. Letters from all my doctors a transition timeline letter. Letter from surgeon. I plan on going to Dr.Zukowski due to him being more proactive accepting insurance. I sent him an email for consultation. So I'm assuming I should make the claim first and then I Appeal the claim? If you would be able to give me assistance from the knowledge you have on this I would really appreciate it! I'm confused as far as the claim goes. Not sure how to make a claim and don't know what the claim needs to have as far as what information the insurance will want? After I get information for Dr.Zukowski then make the claim?

Thanks
Natalia

I set my consultation up with Dr.Zukowski for the 25th. Is he helpful with the process dealing with insurance ?

Hi!!!

Apologies for not getting back sooner, I've been in kind of a funk lately. 

I used Dr Z for FFS.  The first step is a consult.  Do what you feel you need to do, not necessarily what Dr Z wants to do.  I will say that he is an interesting person and he may try to over sell.  However, he is an artist with the face, and arguably, he is the best. 

Once you two agree, he will come up with a total bill.  His office needs to send that into your insurance company for pre-approval.  When he does that, you need to send your two psych letters, the letter from your primary and you may need to book GCS or at least communicate that you are looking for a good doctor.  Communicate by asking your insurance which doctor is in network who performs GCS.  Give them some options.  If you have to book, there are several out there who will give you the letter you need. 

Then you wait for pre-approval. After four weeks, if you don't hear anything, start to call every couple of days.  Eventually, the insurance company will say yes or no.  If it's no, post again and I'll help with the appeal process.

Good luck!!!!!

Hugs,  Jen   

Thanks for the reply Jenn,

I set my consultation with Dr.Z for December 2nd.

About the letters, I have one letter from a therapist and one from a physiatrist. Should they both be from physiatrists? Should I include a letter from my endo? I will get to my primary Doctor that's no issue. And then for the GCS, I plan to do that as well but wanted to get this out of the way first, so you are saying I need a letter from a SRS surgeon as well? Also do I just send all those letters together? I should probably include a letter from Dr.Z with those letters so they are aware of what it's for correct?

So your FFS was covered by insurance? Congratulations! It is well deserved due to the fact that these procedures are medically needed for various reasons as we know. When did you have your FFS?

Thanks
Natalia :)

Update!

Just finished my consultation with Dr.Z we discussed what I needed done and working with insurance. It sounded like he has dealt with it before which I was happy about. I have to send him multiple letters from my doctors and the office is going to send it to the insurance company! I might have to appeal that claim not sure yet.

Lucky girls. In my state BCBS covers nothing. I have to pay cash for everything.......

I have Aetna. My insurance covers srs and hormone, and they follow the WPATH which states that ffs is medically necessary. They might deny this claim but I will have to appeal it somehow let's see what happens. :o

Quote from: FrancisAnn on March 22, 2014, 07:31:38 PM
That is amazing that you were able to organize this & actually receive help from an insurance company. My health insurance is with Blue Cross & I'm sure there is no chance for any help with change/correction of gender.

Anyway good for you GF.

Hi sweetie You are wrong about Blue Cross & Blue Shield I just had SRS with Dr. Marci Bowers in Burlingame California and they paid for everything. I did not even have a co-payment. Please email me tomorrow and I will give you all the right codes and you will win this one for sure

Hugs Lyndsey

Quote from: JLT1 on October 01, 2015, 02:38:49 PM
Do they cover HRT or mention that they follow WPATH?

Jen

Hi Girls
I have BCBS of Illinois and they have paid in full for everything for me so far and not even a co-pay
I do have the top of the line plan threw my work at Sears Holding INC. and they pay for all my insurance too.

Hugs
Lyndsey

Quote from: Pinkkatie on October 07, 2015, 08:07:03 AM
It doesn't mention that they follow WPATH. They are covering HRT for me.

HRT is the easiest to get covered. For one it costs them almost nothing and secondly if your doctor does primary care it can be coded as something else.

Does anybody have experience with SAMBA Health Benefit Plan (federal government)?  The U.S. Office of Personnel Management (OPM) issued a FEHB Program Carrier Letter (Letter No. 2015-12) on June 23, 2015, which specifically states that "Effective January 1, 2015, no carrier participating in the Federal Employees Health Benefits Program may have a general exclusion of services, drugs or supplies related to gender transition or "sex transformations." Yet the 2016 SAMBA plan specifically refuses to cover "surgeries related to sex transformation or sexual dysfunction" (under the appellation Reconstructive Surgery") on the basis that such are considered cosmetic surgeries.  My out-of-network surgeon requested pre-certification as part of a Letter of Medical Necessity.  The surgeries requested included forehead construction, rhinoplasty, mandibular reduction and chinoplasty, and trachea shave.  The letter included my history: mental therapy related to transition, coming out, living full time, hormone therapy, facial hair removal, speech therapy, legal name and gender change, and scheduled GRS for about 18 months out.  The Letter of Medical Necessity was denied on the basis of it being cosmetic.  I appealed citing WPATH's view of medical necessity and not being cosmetic, physicians' recommendations and not being cosmetic, and the OPM FEHB pronouncement, but was again rejected on the basis of FFS being cosmetic.  I second-level appealed, which prompted SAMBA to cynically refer my case to an independent consultant, CIGNA Care Allies, but was again rejected - on the basis of FFS being cosmetic.  Now, the only remaining leg I have available is to appeal directly to OPM according to SAMBA "if we do not follow required claims processes."  Nowhere does it say I can challenge SAMBA's blanket exclusion of FFS, insisting it is cosmetic, which is in flagrant violation of OPM's FEHB Program Carrier Letter No. 2015-12. 

What am I to do?  This seems like total B.S.

Yes, this is BS.

Stop appealing and let's get your ducks in a row.  You need to talk with the office of personal management.  There is a document from OPM that will detail coverage they expect from SAMBA.  Get a copy of that document.

Gather everything togather and show them that SAMBA is not following that agreement.  File a complaint with OPM about SAMBA. 

Also, find your closest HRC office.  Give them copies of everything.  Talk with their attorneys.

More to follow.  This isn't going to be easy....  This is very possible to get done.

Jen

Hi, I am new here and doing srs jan 16 could you tell me who your insurance carrier is?

Shelby

Quote from: shelby2 on December 12, 2015, 10:40:11 AM
Hi, I am new here and doing srs jan 16 could you tell me who your insurance carrier is?

Shelby

here is another data point.  not all insurance coverage is the same from the same insurance carrier.  if you are talking employer based health insurance, depending on the size of the employer the employer has a lot of input on what is and is not covered, also it can vary from state to state.

I have not dealt with a government plan.  I've only helped with insurance provided through companies.  I have had good luck with plans that state they follow WPATH and plans that say they cover gender trasnsition.  We have gotten coverage when FFS was specifically excluded.  We are working on other plans that exclude other parts of a transition.  But there are plans out there that will not cover any part of a transition.  Its all about the plan and not necessarily about the company.

Hugs,

Jen

A well written sample letter from Psych.......

It's written for a MTF who is pre-transition and who is still legally identified as male.  Easy to change the pronouns. 

"To Whom It May Concern:

I am writing this letter to support *FULL LEGAL NAME*'s desire to have facial reconstruction surgery (facial feminization surgery) as part of his/her gender transformation process.  I am basing my opinion on having met with *NAME* on a regular basis since *Date of First Meeting* to facilitate a gender transition.  My diagnostic opinion is that *NAME* has gender identity disorder (302.85).  I have conducted a mental health and substance use assessment and he has no other diagnoses.

*NAME* has met WPATH and other recognized criteria for surgical intervention.  In particular, he has had a marked incongruence between his natal gender and his desired gender dating back to childhood.  He has a strong desire to be rid of secondary sexual characteristics associated with his natal sex and a strong desire to be and live as a woman.  His male sex organs and appearance are a source of significant distress for him and he looks forward to having female physical characteristics that are congruent with his desired gender expression.  *NAME* is over 18 years old.  He has the capacity to make a fully informed decision about feminization surgery.  He has been on feminizing hormones since *date*.  He is getting ready to transition on the job and he has the full support of his employer.  He has the support of his wife and family to undergo this transition.  He is also getting support from the transgender community in *home town*.

I believe this surgery is medically necessary in order to alleviate the psychological distress that he is experiencing surrounding his natal gender and to help him consolidate his desired gender identity.

I certify that I am competent to work with transgender individuals.  I am not part of a formal team but consult on a regular basis with health care providers who have expertise in working with transgender people.  I have worked as adjunct staff at the University conducting their "All Gender Health" Seminars.  I am available for coordination of care and would welcome a phone call."

Hugs,

Jen

Thanks for that sample letter!  I'm trying to find insurance that will for sure cover these surgeries, but can't get a certain answer yet.  Is this considered a pre-existing condition and if I mention that I plan to use the insurance for FFS, will they charge a higher premium versus if I keep my mouth shut and tell them I am perfectly healthy?

Quote from: Lyndsey on December 07, 2015, 11:38:55 PM
Hi sweetie You are wrong about Blue Cross & Blue Shield I just had SRS with Dr. Marci Bowers in Burlingame California and they paid for everything. I did not even have a co-payment. Please email me tomorrow and I will give you all the right codes and you will win this one for sure

Hugs Lyndsey

Could you possibly pm me with the procedure codes. Sorry to bump an old topic,but I'm new here and haven't figured out yet how to pm other users.

I know I'm bumping an old thread but thank you, JLT1. I'm beginning to navigate getting FFS covered by AETNA and this thread is proving to be invaluable. As I type this I'm on the phone with them to see if they follow the WPATH standards. I've already spoken with Deschamp-Braly's office and they will work with me to get pre-certified. I'm going to get letters of medical necessity from my PCP and therapist and submit those along with the letter from the surgeon and see what happens.

Hugs

Jen

Hugs.

I'll update this thread with my results. I'm a federal employee with AETNA Federal as my medical carrier. When I spoke to them yesterday they said the follow "national standards" in regards to GCS so I'm wondering if they mean WPATH.

Quote from: Wynternight on July 12, 2016, 03:02:31 PM
Hugs.

I'll update this thread with my results. I'm a federal employee with AETNA Federal as my medical carrier. When I spoke to them yesterday they said the follow "national standards" in regards to GCS so I'm wondering if they mean WPATH.

Hi Wynternight,

I am also a Federal employee with Aetna.  I had written them before asking if their classification of FFS as cosmetic surgery would change if I could show medical necessity, since they follow WPATH guidelines for GRS and require one year of RLE for pre-certification.  Their response was, "Thank you for contacting Aetna.  FFS is considered cosmetic surgery and is not covered under your policy."  Gee, thanks for explaining that.  I did not pursue it further.

Today I was surprised when Dr. Zukowski's office called me and asked, "why are you only asking for pre-certification for septoplasty?"  I said, because that's the only procedure I could meet their guidelines for.  I have a deviated septum and chronic nasal problems.  They said I should get a letter from my therapist, and Dr. Zukowski would back it up with his professional opinion as to medical necessity and they would send it to Aetna.

I figured that would go nowhere, but then I read the OPM guidance on appeals of denial of coverage, along with OPM Carrier Letter 2015-12, and I figured I would give it a shot.  OPM will review any denial of coverage once you have exhausted your appeals with your insurance carrier.  Letter 2015-12 states that no insurance carrier used by the Federal government "may have a general exclusion of services, drugs, or supplies related to gender transition". For 35 grand, it's worth some time and trouble.

~Terri

I would really appreciate any information you might be willing to share later on outcomes -- I'm yet another federal employee with an AETNA plan.  Thanks so much for what you've posted; it's great info.  Best of luck!

Quote from: SophieD on July 13, 2016, 08:04:27 PM
I would really appreciate any information you might be willing to share later on outcomes -- I'm yet another federal employee with an AETNA plan.  Thanks so much for what you've posted; it's great info.  Best of luck!

You're welcome Sophie. We should all thank Jen for her valiant efforts at pioneering the way to get equitable health care for transgenders.  I think it will be many, many months before things are finally resolved, but I will post any news I get.

~Terri

Lucky you. My blue cross sure does not pay for anything......I've had to pay about $20,000 for plastic surgery so far. ugggg.

This thread is flippin' amazing! I've been wanting FFS as the final step in my journey for over 2 years now. I really wanted to go to Dr. Z for this and now that I found this thread I'm excited at the potential.

I have Kaiser Permanente Northern California through the San Francisco Health Plan. Kaiser has been awesome to me with everything. I just had SRS with Dr. Satterwhite in May paid by my insurance. He also does face work, as that's his specialty, so I wonder if it would be easier to get Kaiser to pay for it since he is an "in-network" provider. I wouldn't mind him doing it all. I LOVE my SRS results. He did a FANTASTIC job. Now the wheels are turning and I will be researching this even further.

Thank you so much Jen for all this information. I copied everything and will definitely get this started.

Hello everyone. First post.

Has anyone had any luck with following the OP advice? I have BCBS of TX (im in AZ, my company is out of tx) and it now covers SRS (scheduled for 2018) and BA (but i already had it done a few years back) but does not cover FFS. My plan description does say "consideration for benefits is guided by the most current standards of care as published by the World Professional Association for Transgender Health WPATH and by the provisions, limitations and exclusions as seth forth by the plan".  I sent an email to my insurance case manager yesterday just asking exactly why FFS is not covered when the latest SOC says it is medically needed... Any advice? thanks!
-A

Quote from: FarfallinAlexa on August 23, 2016, 01:41:47 PM
Hello everyone. First post.

Has anyone had any luck with following the OP advice? I have BCBS of TX (im in AZ, my company is out of tx) and it now covers SRS (scheduled for 2018) and BA (but i already had it done a few years back) but does not cover FFS. My plan description does say "consideration for benefits is guided by the most current standards of care as published by the World Professional Association for Transgender Health WPATH and by the provisions, limitations and exclusions as seth forth by the plan".  I sent an email to my insurance case manager yesterday just asking exactly why FFS is not covered when the latest SOC says it is medically needed... Any advice? thanks!
-A

Hi Alexa,

The only advice I can give you is be prepared for an uphill battle. The language bolded above will be the root of your problems.  As you might have read in my previous post in this thread, I asked my insurance carrier why FFS is  considered elective cosmetic surgery instead of a medical necessary treatment, when RLE is required for the SRS that they do cover, under WPATH guidelines, no less.  The "explanation" was "because we consider FFS cosmetic surgery". As Jen pointed out, her claim was denied multiple times before prevailing.

With kindness,

Terri

I have yet to hear from my insurance case manager. I will try and get a dr to submit a claim and then I will appeal and see what happens. I think it will be worth a shot. Ugh I wished they just covered it and be done with it. Lol thank u

Hi,

I'm the OP.  There have been a number of people who got it.  There have been a couple that won on appeal.  There have been several who gave up.  Most people, I have not heard from.

I'll be posting an updated guide tomorrow. Most often, the failure modes are one of three things: 1.  The insured does not establish medical necessity.  It's in WPATH.  The differences between Men and Women are documented by the Smithsonian. The surgeon needs to state WHY each procedure is medically necessary.  The psych needs to state WHY it is necessary.  If that isn't done, many times, it will fail. Send it ALL in even if they don't explicitly ask for it. Nothing wrong with over kill. 2.  People get frustrated and quit.  Appeals aren't easy.  The time it takes to document everything is significant.  3. The person trusts the insurance company. Don't.  They lie.

More tomorrow.

Hugs,

Jen

An update for me. I tried the pre authorization for FFS win Aetna I went in every letter and info mentioned in this forum and they denied it saying its "cosmetic" so now I have to start the apeal process. I got my response back within 3-4 weeks I'm just posting now because I put the next step on hold due to my recent breast augmentation. I'll post the next steps I take as well on here the more info the more helpful it is for others.

My insurance case manager just answered. 

"Thank you for the email. I appreciate you sending me the WPATH Standards of Care Version 7.

The best way to find out what is covered ahead of time is to talk with the Benefits Value Adviser. Their phone number is Xxxxx. The other option is to speak with your surgeon regarding your interest and his office will submit the request. You will receive a letter either way. This is the first place to start.  It was my understanding the benefit was designed to primarily cover one top and one bottom transitioning. You are correct in that there is a difference between something "medically necessary" and "cosmetic".

I would like to remind you about your travel and lodging benefit of $10,000 available to members during the time they are receiving in-network services within the 48 contiguous states. . This benefit is available to the member and one caretaker."

I'm sorry I had to bump this, this thread is a goldmine of info!!!

Are there specific companies with particular polices that make it easier to win based on the appeals process? I'm thinking if there's some sort of list compiled by state, company and policy plan that'll make it easier for those going down this road.

I have care first Maryland through my employer and don't even know where to begin to even see if srs is covered let alone ffs.

You need to read the policy because one company may write a number of different policies depending on what the pur>-bleeped-< desires. The first place to look is at the exclusions as they tend to spell them out.

Hi Jen, I'm curious to know how you initiated your request for The coverage. My insurance states that it provides   Gender reassignment  surgery  that  is  not  cosmetic in nature. I reside in los Angeles which is pretty trans supportive when compared to other states so maybe i have a bit of a chance.

I'm about to embark on this insurance journey myself, as soon as I settle on a particular surgeon to do the deed.

In my case, my insurer covers SRS but states that FFS and a number of other procedures "are considered cosmetic services and generally non-covered when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender reassignment surgery." So, ignoring that the final clause of the sentence doesn't actually describe me at all, I see that the exclusion only applies "when used to improve the gender specific appearance," which is a verbiage very strongly evocative of the decision in O'Donnabhain v. Commissioner, which in turn centered upon whether a given procedure was truly medically necessary under the WPATH SoC. This will clearly be a very uphill battle, but at least they've left the door open.

The good news is, my therapist is on board with my plans here, and he said I can have a letter signed by the center's full "gender team" of multiple therapists, the managing PhD psychologist, and an advisory MD - the same level of documentation they provide for their patients who need bottom surgery. I've also got a fairly recent state ruling on my side (PA Dept of Insurance Notice 2016-05) which states that insurers "will not deny or limit coverage for a specific health service related to gender transition if such denial or limitation results in discriminating against a transgender individual.'' So, as I see it, my argument goes:

1) My insurance recognizes gender dysphoria as a condition to be treated.
2) FFS is a necessary step in the treatment of my dysphoria.
3) Therefore, this is medically necessary reconstructive surgery for the treatment of a covered condition.

Please let us know how it goes Mandy! =)

Quote from: MandyMarx on December 17, 2016, 04:48:04 PM
I'm about to embark on this insurance journey myself, as soon as I settle on a particular surgeon to do the deed.

In my case, my insurer covers SRS but states that FFS and a number of other procedures "are considered cosmetic services and generally non-covered when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender reassignment surgery." So, ignoring that the final clause of the sentence doesn't actually describe me at all, I see that the exclusion only applies "when used to improve the gender specific appearance," which is a verbiage very strongly evocative of the decision in O'Donnabhain v. Commissioner, which in turn centered upon whether a given procedure was truly medically necessary under the WPATH SoC. This will clearly be a very uphill battle, but at least they've left the door open.

The good news is, my therapist is on board with my plans here, and he said I can have a letter signed by the center's full "gender team" of multiple therapists, the managing PhD psychologist, and an advisory MD - the same level of documentation they provide for their patients who need bottom surgery. I've also got a fairly recent state ruling on my side (PA Dept of Insurance Notice 2016-05) which states that insurers "will not deny or limit coverage for a specific health service related to gender transition if such denial or limitation results in discriminating against a transgender individual.'' So, as I see it, my argument goes:

1) My insurance recognizes gender dysphoria as a condition to be treated.
2) FFS is a necessary step in the treatment of my dysphoria.
3) Therefore, this is medically necessary reconstructive surgery for the treatment of a covered condition.

Perfect. 

Hugs,

Jen

P.S.  If that doesn't work, appeal to the state Board of Insurance.  There is a sample letter in here somewhere.

One thing that is tricky is navigating in-network and out-of-network. I am going to be submitting an FFS consult quote to my insurance next month - I have called and they confirmed that CPT codes for rhinoplasty and forehead work is covered by my plan. However, since it is out of network, I am responsible for 30% of the cost, and insurance uses 'allowed limits' to also make out-of-network really expensive. All FFS surgeons who take insurance are out-of-network that I know of.

Example: Rhinoplasty is billed as $6000, insurance claims this procedure has an allowed limit of $1000, so they will pay 70% of that $1000 and I will pay the rest. This is how I understand it - we will see how they end up covering it. I know that FFS rhinoplasty and forehead work seems to be much more than allowed limits that I can find online are.

Anyone have experience with this?

Hey ladies ! Has anyone gone through the ffs coverage process in Massachusetts ? Moving there soon and would like to know what paper work I need to have done before moving over so that he foot work is done . I know it's the same process as getting srs covering with wpath and all . But how do you even start this process ? I'm going for spiegel and the health plan I'm takin on is Harvard pilgrim or universal health since the receptionist at spiegels office said these two companies are great for the ffs coverage

Quote from: LebanesePrincess on February 13, 2017, 11:55:53 PM
Hey ladies ! Has anyone gone through the ffs coverage process in Massachusetts ? Moving there soon and would like to know what paper work I need to have done before moving over so that he foot work is done . I know it's the same process as getting srs covering with wpath and all . But how do you even start this process ? I'm going for spiegel and the health plan I'm takin on is Harvard pilgrim or universal health since the receptionist at spiegels office said these two companies are great for the ffs coverage

When you are looking at insurance policies, make sure they cover SRS.  Then,  see Spiegal as he submits the paperwork.  I needed 2 letter from psyche, primarily doc and endo.  You will need something beyond just a submission from Siegal.

Good luck.  I did it in 2012.

Hugs

Jen

Hello my name is Daisy. I am just starting my research to find an insurance company that will cover me. I am working a rather low income job, and I am on the state medical at the moment. I live in Fargo ND, and North Dakota dont give any rights to transgender people. I guess what I am trying to get at is: what if any advice would you give to find a supplemental or even a insurance that will cover what I need done. I have been blessed with many features that are very feminine, but others that out rightly scream male! I have been searching, but I am not sure which company to go with. I have been living as a woman since about 2 weeks after I came out in June of 2016, and I have been on HRT since the beginning of October 2016. I have to pay out of pocket for my injections because they will only pay for the pills and patches (which dont really work for me). 

Quote from: Daisy Raine on March 05, 2017, 04:57:18 PM
Hello my name is Daisy. I am just starting my research to find an insurance company that will cover me. I am working a rather low income job, and I am on the state medical at the moment. I live in Fargo ND, and North Dakota dont give any rights to transgender people. I guess what I am trying to get at is: what if any advice would you give to find a supplemental or even a insurance that will cover what I need done. I have been blessed with many features that are very feminine, but others that out rightly scream male! I have been searching, but I am not sure which company to go with. I have been living as a woman since about 2 weeks after I came out in June of 2016, and I have been on HRT since the beginning of October 2016. I have to pay out of pocket for my injections because they will only pay for the pills and patches (which dont really work for me).

Hi Daisy,

Welcome to the site. I am sorry no one has answered you so far. I will post and renew the topic and hope someone has this info for you.

I also want to share some links with you. They are mostly welcome information and the rules that govern the site. If you have not had a chance to look through them, please take a moment:

Site Terms of Service & Rules to Live By (https://www.susans.org/forums/index.php/topic,2.0.html)	Standard Terms & Definitions (https://www.susans.org/forums/index.php/topic,54369.0.html)	Post Ranks (including when you can upload an avatar) (https://www.susans.org/forums/index.php/topic,114.0.html.)
Reputation rules (https://www.susans.org/forums/index.php/topic,18960.0.html)	News posting & quoting guidelines (https://www.susans.org/forums/index.php/topic,174951.0.html)	Photo, avatars, & signature images policy (https://www.susans.org/forums/index.php/topic,59974.msg383866.html#msg383866)

Once again, welcome to Susan's. Look around, ask questions and join in.

With warmth,

Joanna

Quote from: andreah on February 05, 2017, 03:55:08 PM
One thing that is tricky is navigating in-network and out-of-network. I am going to be submitting an FFS consult quote to my insurance next month - I have called and they confirmed that CPT codes for rhinoplasty and forehead work is covered by my plan. However, since it is out of network, I am responsible for 30% of the cost, and insurance uses 'allowed limits' to also make out-of-network really expensive. All FFS surgeons who take insurance are out-of-network that I know of.

Example: Rhinoplasty is billed as $6000, insurance claims this procedure has an allowed limit of $1000, so they will pay 70% of that $1000 and I will pay the rest. This is how I understand it - we will see how they end up covering it. I know that FFS rhinoplasty and forehead work seems to be much more than allowed limits that I can find online are.

Anyone have experience with this?
[/quote, ]

Out of network....  yep, been there done that. 

Many  insurance policies state that if a needed service isn't available in network, they will cover out of network costs at in network levels.  Challenge them. 

If they have a set costyle for a procedure, ask for information as to where they got that number.  Then, appeal. 

Hugs

Jen

Quote from: Daisy Raine on March 05, 2017, 04:57:18 PM
Hello my name is Daisy. I am just starting my research to find an insurance company that will cover me. I am working a rather low income job, and I am on the state medical at the moment. I live in Fargo ND, and North Dakota dont give any rights to transgender people. I guess what I am trying to get at is: what if any advice would you give to find a supplemental or even a insurance that will cover what I need done. I have been blessed with many features that are very feminine, but others that out rightly scream male! I have been searching, but I am not sure which company to go with. I have been living as a woman since about 2 weeks after I came out in June of 2016, and I have been on HRT since the beginning of October 2016. I have to pay out of pocket for my injections because they will only pay for the pills and patches (which dont really work for me).

HI Daisy!!!

I was born in Fargo.  I got my first PhD from UND. I own a small resort not that far away on the Minnesota side...  Work in the Twin Cities though.  Yeah ND isn't exactly transgender friendly. 

Contact the state insurance board for a list of insurers. Then, it's start calling.  Takes a while. 

Wish I had better advice..

Hugs

Jen

Alright, I'm doing this! I've been watching this thread for awhile since I've decided I'm getting FFS, but most importantly, I'm going to get insurance to pay for it one way or another. I'm very patient, but also very committed. It's an uphill battle for sure, but one I hope will help to set a precedent.

Here's my current details:

State: California
Insurer: Anthem Blue Cross
Plan: Prudent Buyer Classic PPO 250-20/10 (modified)

Here's the relevant section of our Anthem policy regarding covered transgender related procedures:

Quote
Transgender Services. Services and supplies provided in connection with gender transition when you have been diagnosed with gender identity disorder or gender dysphoria by a physician. This coverage is provided according to the terms and conditions of the plan that apply to all other covered medical conditions, including medical necessity requirements, utilization management, and exclusions for cosmetic services. Coverage includes, but is not limited to, medically necessary services related to gender transition such as transgender surgery, hormone therapy, psychotherapy, and vocal training.

Coverage is provided for specific services according to plan benefits that apply to that type of service generally, if the plan includes coverage for the service in question. If a specific coverage is not included, the service will not be covered. For example, transgender surgery would be covered on the same basis as any other covered, medically necessary surgery; hormone therapy would be covered under the plan's prescription drug benefits (if such benefits are included).
Services that are excluded on the basis that they are cosmetic include, but are not limited to, liposuction, facial bone reconstruction, voice modification surgery, breast implants, and hair removal. Transgender services are subject to prior authorization in order for coverage to be provided. Please refer to UTILIZATION REVIEW PROGRAM for information on how to obtain the proper reviews.

It's great in that it covers GRS (which I'm getting in 3 days, yippee!) but given that it specifically excludes FFS and other procedures, I know I'm in for quite a bit of denials and subsequent appeals.

What I've done so far:

• Contacted our benefits provider regarding exclusions
• Had consultations with a couple different FFS surgeons

Next up:

• Make an appointment with my GP
• Make an appointment with my therapist
• Gather documentation, specifically official documents that state this is medically necessary as well as the relevant insurance codes (waiting on those from Dr. Z)

I believe the next steps after that would be to submit a pre-authorisation request, await the inevitable denial, then appeal the >-bleeped-< out of it, all the way up to the state board if necessary. Sound about right?



Of note, my company also offers Kaiser, which seems more friendly to non-GRS transgender related procedures as they mention that they may be covered if determined medically necessary, unlike Anthem's more hard line exclusion. Here's what I found after speaking to our benefits provider.

Quote
Transgender surgery is covered as a base benefit for all fully insured DHMO/HMO members with a diagnosis of gender dysphoria. Covered transgender surgical services include genital surgery and mastectomy with chest reconstruction and must be pre-authorized by the Medical Group. Services that are "cosmetic" (i.e., intended primarily to change or maintain appearance) are generally excluded from coverage for all members, unless the services are determined by a Plan physician to be covered as medically necessary reconstructive surgery.

Medical Services to treat gender dysphoria, such as mental health services and hormone therapy, are covered under the base medical benefit or supplemental drug benefit when determined by a Plan physician to be medically necessary.

As of 2016, many Kaiser plans have been offering FFS procedures through a couple local surgeons. Perhaps it makes more sense to wait until open enrolment next year to switch? I'm not sure of the answer yet, nor do I know if we'll even offer Kaiser in the new year, but I do feel it is in my best interests to move forward with Anthem as much as possible. Any progress is good progress!

I might suggest finding out how your current insurer determines medical necessity for procedures not explicitly or implicitly listed. I.e. If it was a treatment or surgery for a super rare condition. This should give you a framework on how to build your case.

For instance my insurer determines medical necessity through best evidence. That is they look for standards of care generally agreed upon in said field. That lacking they look for any peer reviewed research, that lacking they defer to the opinion of the medical provider.

This allows me to use wpaths updated medical necessity statements and specifically their stance on treatment must be customized in the context of specific surgical procedures.


~Brooke~

Quote from: limecat on April 11, 2017, 12:43:40 AM
Alright, I'm doing this! I've been watching this thread for awhile since I've decided I'm getting FFS, but most importantly, I'm going to get insurance to pay for it one way or another. I'm very patient, but also very committed. It's an uphill battle for sure, but one I hope will help to set a precedent.

Here's my current details:

State: California
Insurer: Anthem Blue Cross
Plan: Prudent Buyer Classic PPO 250-20/10 (modified)

Here's the relevant section of our Anthem policy regarding covered transgender related procedures:


It's great in that it covers GRS (which I'm getting in 3 days, yippee!) but given that it specifically excludes FFS and other procedures, I know I'm in for quite a bit of denials and subsequent appeals.

What I've done so far:

• Contacted our benefits provider regarding exclusions
• Had consultations with a couple different FFS surgeons

Next up:

• Make an appointment with my GP
• Make an appointment with my therapist
• Gather documentation, specifically official documents that state this is medically necessary as well as the relevant insurance codes (waiting on those from Dr. Z)

I believe the next steps after that would be to submit a pre-authorisation request, await the inevitable denial, then appeal the >-bleeped-< out of it, all the way up to the state board if necessary. Sound about right?



Of note, my company also offers Kaiser, which seems more friendly to non-GRS transgender related procedures as they mention that they may be covered if determined medically necessary, unlike Anthem's more hard line exclusion. Here's what I found after speaking to our benefits provider.

As of 2016, many Kaiser plans have been offering FFS procedures through a couple local surgeons. Perhaps it makes more sense to wait until open enrolment next year to switch? I'm not sure of the answer yet, nor do I know if we'll even offer Kaiser in the new year, but I do feel it is in my best interests to move forward with Anthem as much as possible. Any progress is good progress!

Welcome to the site.

Wow seems like some very positive steps in the FFS direction. Congratulations. I hope it all goes smoothly.

I also want to share some links with you. They are mostly welcome information and the rules that govern the site. If you have not had a chance to look through them, please take a moment:

Site Terms of Service & Rules to Live By (https://www.susans.org/forums/index.php/topic,2.0.html)	Standard Terms & Definitions (https://www.susans.org/forums/index.php/topic,54369.0.html)	Post Ranks (including when you can upload an avatar) (https://www.susans.org/forums/index.php/topic,114.0.html.)
Reputation rules (https://www.susans.org/forums/index.php/topic,18960.0.html)	News posting & quoting guidelines (https://www.susans.org/forums/index.php/topic,174951.0.html)	Photo, avatars, & signature images policy (https://www.susans.org/forums/index.php/topic,59974.msg383866.html#msg383866)

Once again, welcome to Susan's. Look around, ask questions and join in.

With warmth,

Joanna

I've already had more FFS than should be allowed LOL, but there was something that I was interested in so I asked an FFS surgeon for a quote. After I got the quote, which is in-network, he has to send in a pre-determination, just to see what might be covered. Then after that, he would submit a pre-authorization for the procedure. I'm not holding my breath here because it's a long shot at best. On the other hand, they did approve my GRS in less than a week.

I think what I fear most of all is the window of opportunity to use insurance closing should they repeal the ACA. There's really no telling how fast our friendly State Legislators will move to deny and exclude transgender people healthcare coverage due to pre-existing conditions, given the slightest opportunity.

When I was in the hospital after GRS I found it revealing that so many nurses were curious about whether my insurance was covering the surgery. That bugged me even though I didn't tell them one way or another.

Hi,

I had kind prior to ACA.  If they cover any part of over gender transition, you can, with effort, get coverage..  However, it's probably  easier with ACA in place..

Hugs


Jen

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?

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

Dear stephbertenshaw

Welcome to Susan's

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I also want to share some links with you. They include helpful information and the rules that govern the site.  It is important for your enjoyment of the site to take a moment to go through them

Site Terms of Service & Rules to Live By (https://www.susans.org/forums/index.php/topic,2.0.html)	Standard Terms & Definitions (https://www.susans.org/forums/index.php/topic,54369.0.html)	Post Ranks (including when you can upload an avatar) (https://www.susans.org/forums/index.php/topic,114.0.html.)
Reputation rules (https://www.susans.org/forums/index.php/topic,18960.0.html)	News posting & quoting guidelines (https://www.susans.org/forums/index.php/topic,174951.0.html)	Photo, avatars, & signature images policy (https://www.susans.org/forums/index.php/topic,59974.msg383866.html#msg383866)

 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!

Quote from: stephbertenshaw 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

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

Great info! Thanks, I have CIGNA OAP in Maryland, anyone have experience with them?

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.

Does  any one know of two court cases at all. My insurance blue shield California rejected  me again for third time

Hi Stephaniek  :icon_wave:

Welcome to Susan's Place  :)  Glad to have you here, join on in the fun

How about stopping by our Introductions (https://www.susans.org/forums/index.php/board,8.0.html) Forum and introducing yourself so more folks can get to know you a bit better  ;)

Here are some links to the site rules and stuff that we offer to all new members to help them along

Site Terms of Service & Rules to Live By (https://www.susans.org/forums/index.php/topic,2.0.html)	Standard Terms & Definitions (https://www.susans.org/forums/index.php/topic,54369.0.html)	Post Ranks (including when you can upload an avatar) (https://www.susans.org/forums/index.php/topic,114.0.html.)	Cautionary Note (https://www.susans.org/forums/index.php/topic,82221.0.html)
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Hugs

V M

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.

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.

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

Wow this immensely helps. I'll be sure to try and do this. Thank You!