How I got FFS Paid for by Insurance

[Alaia]

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:

The 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:

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."  [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

[gslvqz]

This could leave an opening to contest FFS coverage as WPATH v7 standards have a medical necessity statement:


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

[deeiche]

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.

[Rachel]

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.

[lemons]

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!

[Rachel]

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.

[Lauren Nicole]

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!

[JLT1]

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

[gslvqz]

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

[Alaia]

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.

[gslvqz]

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

[Alaia]

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.

[samogal]

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.

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

[samogal]

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 

[dex_paradox]

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.

[Sincerely Sophie]

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.

[JLT1]

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

[Serena]

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?

[clearleeraines]

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  Clear

[Pinkkatie]

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.