Hey everyone. A little background: I MTF transwoman. Been on hormones for a while and now just wrapping up some of my last surgeries. I am currently 12 days post op from my breast augmentation that I paid $0 for because it was covered by insurance and considered reconstructive in nature.
Here was my process:
1. Have health insurance
2. Go to a plastic surgeon you wish to have surgery with that is within your health care network.
3. Ask their office to seek pre authorization for the surgery
4. You will get a denial in the mail (most likely) from your insurance. This is when you file a grievance through your health insurance. (
http://www.dmhc.ca.gov/fileacomplaint.aspx#.VqEtXfldWSo)
5. If you get denied again you will have to file an Independent Medical Review (IMR) with the Department of Managed Health Care (DMHC). The DMHC is an agency comprised of lawyers who argue about the ethical medical treatment of patients. They can overturn a health insurance company's denial for a procedure/treatment if they find it will benefit you, regardless if your insurance covers it. They are a third party government agency that can legally force a procedure to be covered if it is considered unethical to deny it.
(
http://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForm.aspx#.VqEugvldWSo) <--- IMR form
6. You will hear back and hopefully get it covered.
You must argue your side. How does this interfere with your daily life? Does your gender dysphoria prevent your from going to work, school, social etc? Can you afford it? Is this specific thing within normal range of a female's? Does having the incorrect hormones (extreme hormonal imbalance) cause your body to change in a way that is unnatural for a cis female? Did you try earning money (illegally) to pay for it only to be left with traumatizing scars that further damaged you? Does it cause suicidal tendencies or other emotional trauma? How would this procedure change your life? Why is it not cosmetic?
I was advised by a lawyer specializing in transgender rights to make this argument very personal. DO NOT say "all transwomen should have this covered because SRS is covered and it only makes sense since they are similar." If you argue for everyone versus yourself, it would be setting a HUGE legal precedence that would be very difficult to change. There are lawyers who are fighting for trans-rights in the supreme court. The DMHC's Independent Medical Review is not the outlet to fight for trans rights, it is to get your individual procedure covered because it is medically necessary for your health. You are not a lawyer (most likely) and do not want to get involved into a messy legal battle that could take decades. You want to get YOUR procedure covered because you are suffering, because you have a pre-existing medical diagnosis/physical condition/hormonal disorder that causes you anguish and a physical change on your body that HRT has not been able to treat.
Make your argument as strong as possible. I broke my into physical, mental and social. Try to back it up with as much well researched data as possible. Use medical lingo. Provide documents from doctors and therapists that support your claims.
Good luck =)
