How I got FFS Paid for by Insurance

[New2Brooke65]

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.

[JLT1]

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

[shelby2]

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

Shelby

[deeiche]

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.

[JLT1]

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

[JLT1]

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

[shoko]

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?

[Dieharlot]

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.

[Wynternight]

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.

[JLT1]

Hugs

Jen

[Wynternight]

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.

[Maybebaby56]

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

[SophieD]

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!

[Maybebaby56]

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

[FrancisAnn]

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.

[Melia02]

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.

[FarfallinAlexa]

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

[Maybebaby56]

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

[FarfallinAlexa]

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

[JLT1]

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