Help with Insurance Strategy

[katiej]

I'm in the process of fighting with my insurance company to get them to cover hair transplant surgery. And I'm wondering if any of you have any experience or advice that could help.

I met with a local LGBT attorney, and she laid out the general strategy. This is a medically necessary procedure to help with my "persistent and severe gender dysphoria". It's not cosmetic, so she said not to even mention passing.

My doctor submitted the initial pre-authorization, and it was denied...as expected. So now I'm going through the appeals process, where we think I have a decent shot.

My appeal paperwork includes:

- A letter from me that is half impassioned plea, and half quotes from WPATH. I also mention that the doctor who would do the procedure has had insurance cover this for cancer patients when deemed medically necessary. So it's discrimination if they're covered but I'm not.

- A letter from my doctor stating the medical necessity

- A letter from my therapist describing the effect of gender dysphoria and explaining the medical necessity

- A letter from my state's (Washington) insurance commissioner stating that they cannot deny me for services that would be available to others.


Am I missing anything? What would you all suggest?

[Christinetobe]

It all sounds good.  I would just stress that anytime you talk to a rep from the company write dodown the name and get a contac or extension to call them back. It really helps with appeals also make copies of everything and all appeals have to be in writing.  I am a case manager for a national insurance company and they will so anything to have it dismissed

[Tessa James]

I went thru the three steps of appeal to get my orchiectomy and eventually Kaiser changed policy.  Be prepared for a fight that hurts when total strangers will deny you and say it is all cosmetic.  The WA insurance commission has been supportive so good luck to you.

[JoanneB]

I give you a snow-balls chance in H.... It will be a major uphill battle for you to get the insurance company to fold. Hair transplants, like a BA is cosmetic.

Insurance companies are not in business to give away money. Unless you live in a state or a municapality or your policy has all sort of Trans treatment spelled out, they have rooms full of lawyers they pay no matter what.

[katiej]

Joanne, in most states you'd be right. But things seem to be changing here in Washington.

The wording in my policy is vague. I imagine intentionally so. It only says that they cover "medically necessary procedures for gender reassignment."  But after talking to them, I now know they cover SRS, orchis, HRT, therapy, and voice therapy. So if I can demonstrate the medical necessity of hair restoration in my case (which WPATH supports), I think I have maybe a 50/50 chance.

But I do understand insurance companies' job is to collect our money and pay out as little add as possible.

Worst case I go through the appeals and they still say no, I'd have to just pay for it myself.

Wish me luck!

[katiej]

Hair transplants, like a BA is cosmetic.

Not necessarily. WPATH says, "Although it may be much easier to see a phalloplasty or a vaginoplasty as an intervention to end lifelong suffering, for certain patients an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria."

For a guy, hair restoration is cosmetic. But for me, it's about treating my severe and persistent gender dysphoria.