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How I got FFS Paid for by Insurance

Started by JLT1, March 21, 2014, 10:51:04 AM

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0 Members and 1 Guest are viewing this topic.

Rachel

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.
HRT  5-28-2013
FT   11-13-2015
FFS   9-16-2016 -Spiegel
GCS 11-15-2016 - McGinn
Hair Grafts 3-20-2017 - Cooley
Voice therapy start 3-2017 - Reene Blaker
Labiaplasty 5-15-2017 - McGinn
BA 7-12-2017 - McGinn
Hair grafts 9-25-2017 Dr.Cooley
Sataloff Cricothyroid subluxation and trachea shave12-11-2017
Dr. McGinn labiaplasty, hood repair, scar removal, graph repair and bottom of  vagina finished. urethra repositioned. 4-4-2018
Dr. Sataloff Glottoplasty 5-14-2018
Dr. McGinn vaginal in office procedure 10-22-2018
Dr. McGinn vaginal revision 2 4-3-2019 Bottom of vagina closed off, fat injected into the labia and urethra repositioned.
Dr. Thomas in 2020 FEMLAR
  • skype:Rachel?call
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JLT1

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

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.
HRT  5-28-2013
FT   11-13-2015
FFS   9-16-2016 -Spiegel
GCS 11-15-2016 - McGinn
Hair Grafts 3-20-2017 - Cooley
Voice therapy start 3-2017 - Reene Blaker
Labiaplasty 5-15-2017 - McGinn
BA 7-12-2017 - McGinn
Hair grafts 9-25-2017 Dr.Cooley
Sataloff Cricothyroid subluxation and trachea shave12-11-2017
Dr. McGinn labiaplasty, hood repair, scar removal, graph repair and bottom of  vagina finished. urethra repositioned. 4-4-2018
Dr. Sataloff Glottoplasty 5-14-2018
Dr. McGinn vaginal in office procedure 10-22-2018
Dr. McGinn vaginal revision 2 4-3-2019 Bottom of vagina closed off, fat injected into the labia and urethra repositioned.
Dr. Thomas in 2020 FEMLAR
  • skype:Rachel?call
  •  

Ali

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

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:
Allyda
Full Time August 2009
HRT Dec 27 2013
VFS [ ? ]
FFS [ ? ]
SRS Spring 2015



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JLT1

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

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!!! 
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lemons

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...
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JLT1

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

gslvqz

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
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Rachel

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.

HRT  5-28-2013
FT   11-13-2015
FFS   9-16-2016 -Spiegel
GCS 11-15-2016 - McGinn
Hair Grafts 3-20-2017 - Cooley
Voice therapy start 3-2017 - Reene Blaker
Labiaplasty 5-15-2017 - McGinn
BA 7-12-2017 - McGinn
Hair grafts 9-25-2017 Dr.Cooley
Sataloff Cricothyroid subluxation and trachea shave12-11-2017
Dr. McGinn labiaplasty, hood repair, scar removal, graph repair and bottom of  vagina finished. urethra repositioned. 4-4-2018
Dr. Sataloff Glottoplasty 5-14-2018
Dr. McGinn vaginal in office procedure 10-22-2018
Dr. McGinn vaginal revision 2 4-3-2019 Bottom of vagina closed off, fat injected into the labia and urethra repositioned.
Dr. Thomas in 2020 FEMLAR
  • skype:Rachel?call
  •  

JLT1

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
To move forward is to leave behind that which has become dear. It is a call into the wild, into becoming someone currently unknown to us. For most, it is a call too frightening and too challenging to heed. For some, it is a call to be more than we were capable of being, both now and in the future.
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JLT1

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
To move forward is to leave behind that which has become dear. It is a call into the wild, into becoming someone currently unknown to us. For most, it is a call too frightening and too challenging to heed. For some, it is a call to be more than we were capable of being, both now and in the future.
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JLT1

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.
To move forward is to leave behind that which has become dear. It is a call into the wild, into becoming someone currently unknown to us. For most, it is a call too frightening and too challenging to heed. For some, it is a call to be more than we were capable of being, both now and in the future.
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JLT1

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

JLT1

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

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.
HRT  5-28-2013
FT   11-13-2015
FFS   9-16-2016 -Spiegel
GCS 11-15-2016 - McGinn
Hair Grafts 3-20-2017 - Cooley
Voice therapy start 3-2017 - Reene Blaker
Labiaplasty 5-15-2017 - McGinn
BA 7-12-2017 - McGinn
Hair grafts 9-25-2017 Dr.Cooley
Sataloff Cricothyroid subluxation and trachea shave12-11-2017
Dr. McGinn labiaplasty, hood repair, scar removal, graph repair and bottom of  vagina finished. urethra repositioned. 4-4-2018
Dr. Sataloff Glottoplasty 5-14-2018
Dr. McGinn vaginal in office procedure 10-22-2018
Dr. McGinn vaginal revision 2 4-3-2019 Bottom of vagina closed off, fat injected into the labia and urethra repositioned.
Dr. Thomas in 2020 FEMLAR
  • skype:Rachel?call
  •  

gslvqz

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
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JLT1

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

gslvqz

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!
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