How to Get Electrolysis for GCS Approval from BlueShield CA

[sarahla]

Does anyone know the procedure in California (might be independent of State in the U.S.), whereby I can get BlueShield to cover electrolysis?

My GP has already indicated that he will write a letter. I know that my electrologist is already on the BlueShield list, just I do not know the procedure. Sadly, contacting BlueShield is next to impossible and even if I get a human on the phone, this topic is completely over their head. Sending in a message through the online system yields the same result, nothing.

I already know that BlueShield, presumably like every other health plan now in the U.S., already covers electrolysis for GCS/GRS.

I realize that going to "my chosen surgeon" would solve this problem, however I am still deciding which one. My GP is not familiar with the procedure as well as I am not, so I am hoping someone here knows the step-by-step procedure for BlueShield.

[I Am Jess]

I just went and got it done then submitted the bill to them for reimbursement (Anthem Blue Cross).  You may need to get your doctor's authorization and have your electrologist submit for prior approval.  If he/she is already a covered provider, he/she should know the approval process.  Good luck.

[sarahla]

I talked with my electrologist yesterday evening on this topic. I do not want to paraphrase what she said, as I would get it wrong.

I will forward her your comment and see what she says. In the mean time, I will ask my GP to write a letter.

Maybe, just submitting the request is the best way, although that could be an issue, because they could say, as what happened with my allergy injection a few months back, that the first claim is denied for whatever reason and then a subsequent claim is also denied because they ruled declined the first time out. The office had a change legal change.

I am a bit gun shy and just want to make sure that things are done properly with nothing bad happening.

Stay tuned.

[I Am Jess]

If it is in your coverage and they then refuse to pay and deny your valid claim you can file a complaint with the California Department of Managed Health Care. That's what I did when Anthem at first denied my claim.  I appealed but didn't hear back within 30 days so I filed a complaint.  Shortly after that I was notified that it was covered.  I then received notification that they were reimbursing me the full amount of my GRS surgery fee even though I went with an out of Network doctor. 

I never got a referral letter.  I just submitted a master bill with a claim form.  Make sure that it is a covered procedure in your policy (it should be).   

[sarahla]

Thanks for the response and your experience. That helps. There are so few people that go through GRS in California, at least from an insurance company point of view, that Anthem is not the most helpful simply because their staff do not know the correct procedures or even heard of transsexual anything, except with relation to bathroom access and maybe now North Carolina.

1. What did you mean by "master bill"?

2. Where did you find if electrolysis and GRS/GCS is a covered procedure? I have Anthem BlueCross for a few more days, so can use that for research and then when I get access to BlueShield determine that.

[I Am Jess]

The master bill was basically a single bill showing the dates of service and payments made.

You should have a booklet that lists the terms of coverage.  You can usually find it online in your account.  In your online account there should be a tab listed benefits with a link titled view my plan documents. It will be a PDF file that you can search for the term transgender to find the section titled transgender services.


I found that I was having to tell the people I was dealing with what was needed. It worked out in the end with my getting most of my surgical costs reimbursed by them.

[SadieBlake]

Because my electrologist doesn't know how to deal with insurance I submit a subscriber claim form which may be a different document at blue ca

Afaik the diagnosis code you need is F64.9

Electrolysis procedure code is 17380

Have to go through your PCP and have a referral in place before going for the work

[sarahla]

I finally got access to my BlueShield online account; small victory.

BlueCross of California:
I downloaded the 2016 PPO "Combined Evidence of Coverage and Disclosure Form" and on page 119, there is an explicit section that grants coverage (not that they have a choice in the matter).

Benefits are provided for services and supplies in connection with Gender Transition when a Physician has
diagnosed You with Gender Identity Disorder or Gender Dysphoria. Benefits are provided according to the terms and
conditions of this Agreement that apply to all other medical conditions, including Medical Necessity requirements,
Precertification and exclusions for Cosmetic Services. etc..

BlueShield of California
Okay, the "Evidence of Coverage and Health Service Agreement" for the PPO, and there is not one mention of "Transgender Services", "transgender", "transsexual", "gender", "dysphoria", or any of several other terms. There is absolutely nothing mentioned. That is "as expected" as I out.

I found this link (through Google):
http://insuremekevin.com/blue-shield-gender-reassignment-surgery-criteria/

Kevin said at the top:

Solid information is hard to come by when it relates to what health insurance plans will cover for gender reassignment surgery in California. In response to the Insurance Gender Non-Discrimination Act passed by California in 2013, some health plans have created detailed medical policies for transgender health benefits. For a variety of reasons the health insurance companies don't make their policies readily available to the general public. I was able to locate two detailed outlines issued by Blue Shield of California relating to gender reassignment surgery.
Read more at http://insuremekevin.com/blue-shield-gender-reassignment-surgery-criteria/#CEgfOee6kTADhyOf.99

I heard of the Insurance Gender Non-discrimination Act, AB 1586, http://insuremekevin.com/transgender-health-benefits-remain-elusive-california/.

According to Kevin's site, the procedure for Anthem BlueShield of California is the same as that for Anthem BlueCross of California, which should be the same for no matter which health insurance company operating in California.

Others can clarify this point, but I thought that the Affordable Care Act (ACA) duplicates what California said, namely that health plans must cover transsexual surgeries, at least until Republicans "Repeal and Replace".

Hopefully, my electrologist will have time to respond to me and I will post back. I hope that I can simply just file a claim form. It is time to get the show on the road to being me.

[sarahla]

Thanks Sadie for the information.

What does "have a referral in place" mean before going for the work mean? I understand the term with respect to an HMO. Patients have a PCP with an HMO, who then refers their patients to specialists (dermatologist, whatever). There is no such thing in a PPO and no such thing as a PCP. Am I missing something?

[SadieBlake]

Thanks Sadie for the information.

What does "have a referral in place" mean before going for the work mean? I understand the term with respect to an HMO. Patients have a PCP with an HMO, who then refers their patients to specialists (dermatologist, whatever). There is no such thing in a PPO and no such thing as a PCP. Am I missing something?

I've never been insured through a PPO so yeah I'd assume you still need to have a provider who's in their network. The electrologist/laser offices I know affiliate with a physician and her provider ID is registered with the insurer.