Demonstrating medical necessity of a certain surgeon to perform my FFS revision

[mistyjensen]

Hi,

How can I demonstrate to my insurance that it's medically necessary for me to have an out-of-network surgeon perform additional FFS procedures? I recently learned that my insurance will likely pay an out of network surgeon, who has extensive experience performing FFS, to perform on me a revision of a jaw reduction surgery that I had for facial feminization. My insurance will do this because of a dental problem I have. But my insurance will not pay for the other FFS proceedures the surgeon recommended for me. The insurance argues that my documentation doesn't show why it's medically necessary for them to go out of network for me to have these additional procedures performed by the surgeon when there are in network surgeons. I'm surprised at this late stage of deliberations between my insurance and the surgeon's office that my insurance is resorting to this strategy. They were the ones a few months ago that indentified the well known surgeon as the best candidate to perform my FFS revision and that they were willing to meeet the surgeon's rates.

I don't want to go through multiple surgeries with different surgeons to have the comprehensive FFS revision that I need.

[Dani]

FFS is a very important gender confirming surgery and should be documented as medically necessary by your therapist. This should be enough, but insurance companies are good at deny, delay and defer anything that particular agent wants.

What ever, get prior authorization and be prepared to show why an in network surgeon cannot do the surgery.

Good luck and if you get even partial coverage, be thankful. Many of us got nothing from insurance.

[mistyjensen]

Hi,

Thank you for your message.

I already had FFS.

To clarify my previous remarks, I don't need to demonstrate the medical necessity of the additional proceedures - my trans friendly insurance gets their importance . An out-of-network surgeon my insurance chose to perform a revision of the jaw reduction I had as part of my original FFS recommended these procedures. I have to prove why it is medically necessary for just the out-of-network surgeon to perform all of the other FFS procedures he recommend for me within the context that there are in-network surgeons who perform those procedures.  In its current form my medical documentation only supports that it is medically necessary for an oral and maxillofacial surgeon given a major dental problem I have to perform further jaw reduction on me for facial feminization. I hope that better clarifies matters.