How I got FFS Paid for by Insurance

[audreelyn]

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

[JLT1]

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

[JLT1]

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

[Pinkkatie]

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.

[Madithias]

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):

Transwomen 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:

Psychiatric 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?

[Rachel]

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[JLT1]

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

[JLT1]

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

[sfbarbie]

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

[JLT1]

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

[Nattiedoll]

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

[Nattiedoll]

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

[JLT1]

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   

[Nattiedoll]

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

[NataliaDoll]

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.

[FrancisAnn]

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

[NataliaDoll]

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.

[Lyndsey]

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

[Lyndsey]

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

[iKate]

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.