I'll also jump in here.
I don't have experience with Aetna, but I do have tons of experience with medical insurance coverage for procedures and services that are not covered.
First bit of advice, know what you are getting yourself into- know the game.
Insurance companies are counting on you giving up. If you're patient and diligent you have a much better chance.
You have to prove medical necessity, and any harm that is occurring due to not being able to have the surgery.
The letters from your providers need to be in network. Talk with your gender therapist about a recommendation.
Find the Aetna surgeons who are contracted for GCS. I know it's not on your plan but at least there is a relationship set up between the surgeon and carrier.
Once you've found the surgeon and have the letters/requirements from insurer in place try to get a referral for a consult. Make sure to ask the surgeons billing department to confirm the consult is covered by insurance. If it's not work on that auth for consult.
Okay, you've had the consult, you like the doctor, and want to proceed. Have the surgeons billing department submit for a prior authorization/PA.
Expect a Denial letter within 30 days.
Make copies of the Denial letter, letters of medical necessity, proof you have met Aetnas requirements for GCS.
Also make sure that you have the letter of recommendation, and specific procedures with icd10 billing codes and diagnosis codes for gender identity.
Check your polices guidelines for any guidelines of coverage being determined by medical necessity. If you find it, send in that section with a
bit.ly link adhered to it- for full text, and context.
Print out the updated wpath medical necessity guidelines and include in the 1st appeal.
Check the Denial letter for exact verbiage of the non coverage decision and address that in your appeal letter with any additional documentation, or the resources from above.
Send in the appeal and again, expect a Denial letter. This letter may contain different verbiage for the Denial reason.
If the denial reason listed is "not covered by your policy " check your full policy for anything related to care approval based on medical necessity or what the insurance companies procedure is for services/procedure not listed. Often there will be guidelines for rare conditions and what needs to be done for auth.
At this point you may be looking at a fair hearing, or review.
Prepare with everything that you can. Full wpath SOC, all letters etc. Look around for pretext or precedents that others have used in similar situations with private insurance. What was their key evidence/strategy.
At this point you may also want to contact the transgender law center for advice and additional resources.
The biggest take away is most of the time persistence, patience and diligence pays off.
For every day that your insurance company doesn't have to pay out, that is money that can be invested, earning them returns.
Learn how to become a professional hoop jumper. Don't take it personally, and make sure you have covered every angle in your case. If they find an undotted I or uncrossed T they will exploit it.
Most people don't get coverage because they give up, get frustrated, or don't want to wait for the entire process to be completed.
The 3 Ds of insurance.
Defer
Deny
Delay
You know the game now. If you can play by their rules and understand their logic, you have a far better chance than most.
I have done this with my own rare health conditions and have won almost every time. (Prolly 18/20 appeal processes).
I'm currently in a similar process for hair removal and surgery.
Good luck!
Brooke
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