FFS Coverage Denied by Insurance. Help with Appeal!

[SophiaS]

Hello Everyone!

I'm sure some of you have gone through the painfully tedious process of working with insurance. I am getting FFS with Dr. Keojampa in LA and he sent some info to my insurance (Blue Shield of CA) for pre-authorization but it got denied. I was expecting this to happen and I am aware of the need to appeal.

Could any of you lovely ladies help me with the appeal part of the process? I know what I need to a certain extent as I have been researching this and have also read some threads here. But if I could be as prepared as possible to get this approved with little hassle that would be amazing.

So I was wondering if someone who has successfully gone through this with FFS, could provide me with example letters of recommendation by your doctors/therapists/surgeon, the letter of appeal and any other important information I should send to my insurance?

This process is daunting and I am losing my patience and composure, I would really appreciate some help!

[Dena]

Welcome to Susan's Place. I am moving this thread to the FFS section of the site because handling insurance for FFS is a bit different that with surgeries like GCS. I don't remember the name of the member but a member was successful with the appeal process over a year ago and posted about the process. With a little digging you might find these posts and in the meantime I will see if I can add anything to this.

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[Dena]

Ok, the member was JTL1 and while there may be more than one thread, you might want to start looking here.

[Denise]

I've been debited too.  They want letters of medical necessity, photos, descriptions of procedures, CPT codes.  I strongly suggest that the surgeon call and request a peer-to-peer review.  Once you appeal the decision  blue Cross will not accept the peer to peer option.

That's where I am.

Sent from my LG-H910 using Tapatalk

[ainsley]

I've been debited too.  They want letters of medical necessity, photos, descriptions of procedures, CPT codes.  I strongly suggest that the surgeon call and request a peer-to-peer review.  Once you appeal the decision  blue Cross will not accept the peer to peer option.

That's where I am.

Sent from my LG-H910 using Tapatalk

So, I just submitted a request for a network gap exception and preauthorization for FFS with UHC.  Why don't they ask for these items (letters, photos, etc.) before they deny you for a covered service?  I've not been denied, yet, but I expect to be, just from reading how others have been.  I mean, really, if the procedure is covered under my summary plan description, then why is it a deny right out of the box and then a requirement that we jump through so many hoops to get what is available to us?  So frustrating. 

It's like they sit back, laugh, and say "Yea, we'll add trans-care for srs, ffs, vfs, in the coverage, but we are going to make it soooo complicated and make them go thru so much to do it they will never get it submitted right and they will just give up.  hahahaha!"  <insertSwearWords>

[Maria77]

Capitalism.  Reduce costs.  Perhaps a crazy anti-lgbt insurance employee, etc.  there are so many factors atmwork. 

[ainsley]

So, as suspected I was asked for more information.  This is what the request asked for:

Description of services
Procedure code 30400/21120/21137/40799
Procedure description
Rhinoplasty, primary; lateral and alar cartilages and/or elevation of
nasal tip. Genioplasty; augmentation (autograft, allograft, prosthetic
material). Reduction forehead; contouring only. Unlisted procedure,
lips

Please provide the information listed below:
1. For Breast Surgery - a written Psychological assessment is needed from at least one
qualified behavioral health provider experienced in treating gender dysphoria. The
assessment must document that an individual meets ALL of the following criteria:
2. - Persistent, well-documented Gender Dysphoria
3. - Capacity to make a fully informed decision and to consent for treatment
4. - Must be at last 18 years of age (age of majority)
5.
6. If significant medical or mental health concerns are present, they must be reasonably well
controlled.
7.
8. For Genital Surgery - a written Psychological assessment is needed from at least two
qualified behavioral health providers experienced in treating gender dysphoria. The
assessment must document that an individual meets ALL of the above criteria, as well as:
9. - Complete at least 12 months of successful continuous full-time real-life experience in the
desired gender
10. - Complete at least 12 months of continuous cross-sex hormone therapy appropriate for the
desired gender (unless medically contraindicated).
11.
12. For all requests, a treatment plan that includes ongoing follow-up and care by a qualified
behavioral health provider experienced in treating gender dysphoria must also be submitted.

Having already paid out of my own pocket for srs, ba, & vfs, it is obvious that they are just doing the standard form request here and took no time to understand that I have satisfied WPATH's standards.  Do people with cancer, diabetes, COPD, or other conditions have to go thru this scrutiny?  Yes, this is a mini rant.

I faxed 19 pages in, and Dr. Spiegel's office faxed in my office visit clinic notes.  It is frustrating that having been on hormones for a decade and paid for all of my trans* care thus far that I have to go thru such hoops for medically necessary care, and covered services in my plan.  None the less, I will push forward.

[Colleen_definitely]

Yes, actually my friend who just had 7" of his colon removed and is currently undergoing chemo is having similar requests from his insurance. 

I understand that it isn't a charity but these people are just jerks about it.

[ainsley]

Yes, actually my friend who just had 7" of his colon removed and is currently undergoing chemo is having similar requests from his insurance. 

I understand that it isn't a charity but these people are just jerks about it.

That sucks!  Makes me angry to hear that about your friend.  I had 12" of my colon taken out and 1.5 years of chemo, but I never was asked for more info.  Tell your friend I feel for him and wish him a speedy and full recovery!!

[Colleen_definitely]

Thankfully his wife is angry and Italian so she is an absolute terror on the phone when she's in the mood.  She had fun sorting them out over the phone.

As for how he's doing, so far quite well.  He's 2 doses in and so far just mild nausea, cold sensitivity (welcome to my world dude), and peripheral neuropathy.  Fingers crossed.  Thankfully he also only has to do this for 12 or 13 weeks.  It's one hell of a regimen though.

So what I'm getting out of their request is that they want fresh letters because, well I have no idea why they'd think GD would simply not persist.  It's basically like what I'm assembling for documentation.  One letter from my therapist, one from a PhD shrink saying "yep, that therapist isn't lying," and I'm going to get one more from my endo saying "she's not lying about being on HRT for longer than 12 months either."

The therapist and endo letters are easy the shrink I got referred to is an incompetent boob with zero time management skills or motivation.  Thankfully I found a plan B but I don't see her for a few weeks.

[ainsley]

Thankfully his wife is angry and Italian so she is an absolute terror on the phone when she's in the mood.  She had fun sorting them out over the phone.

As for how he's doing, so far quite well.  He's 2 doses in and so far just mild nausea, cold sensitivity (welcome to my world dude), and peripheral neuropathy.  Fingers crossed.  Thankfully he also only has to do this for 12 or 13 weeks.  It's one hell of a regimen though.

So what I'm getting out of their request is that they want fresh letters because, well I have no idea why they'd think GD would simply not persist.  It's basically like what I'm assembling for documentation.  One letter from my therapist, one from a PhD shrink saying "yep, that therapist isn't lying," and I'm going to get one more from my endo saying "she's not lying about being on HRT for longer than 12 months either."

The therapist and endo letters are easy the shrink I got referred to is an incompetent boob with zero time management skills or motivation.  Thankfully I found a plan B but I don't see her for a few weeks.

Good to hear!  Having an advocate in that situation is critical.  My wife was my caregiver and advocate and she was extraordinary in her dispatch of those duties.  I hope he tolerates the regimen and it works for him.  I really do.  It touches my heart to hear people go through what I did and I know how brutal it can be to endure. I had nephropathy and that was awful!  It all rings so familiar to me. 

I also have the same line of thought with my FFS info request: As if my GD is no longer persisting??  You need more verification??  For fuggs sake!  I will be interested to see how yours plays out.  I have the impending doom feeling from my submissions, and suspect they will come back with a request for fresh and specific therapist/PhD letters, photos, etc.  :rollsEyes:

[Colleen_definitely]

I know my insurance wants letters specifically for ffs and separate ones for srs, so I'm not surprised. I do know of a good shrink in KC for the PhD letter. I also know of one to avoid like the plague in St Louis.