Top Surgery: Process in the US?

[Linus]

Ok. I've reached my limit and desperately want to get top surgery. I now live in Redondo Beach, CA and have been on T for nearly 3 years. My company recently switched to Aetna as a health benefits provider and I'd like to see if I can get them to cover some or all of the surgery. What puzzles me, since I'm Canadian, is the exact process.

Do I find a surgeon first and then apply for coverage or ..?

Can someone help a confused Canuck figure this out? Also, if anyone is on Aetna and has had it covered completely in the L.A. could you let me know how you found your surgeon and were they any good? One of the things that concerns me is that none of the known surgeons in the L.A. and surrounding areas will take any insurance, let alone Aetna. So that means potentially going to a regular plastic surgeon who may not be as good as others. Or facing worse.. discrimination.

[Robert Scott]

Call your insurance company and find out what they cover ... find out what doctors are covered under your insurance and set up a consultation with one and ask them to see how much is covered - both routes could get your the answer you want

[Noah G.]

I'm currently covered under my mother's insurance and she has Aetna (it's also the insurance the company I work for has available as well). I just wanted to chime in and give a heads up to not be surprised if they won't cover top surgery -- my ma told me that she looked but couldn't find a plan that covered the surgeries, because she planned to switch for me if she could. I don't know if that was just for the plans she could choose from through her work though, because I didn't ask any questions (I haven't expected to find insurance to cover much for a while now). So perhaps they do have a plan or plans, but they're just not available to her.

It's worth checking into at the least.

I've also heard of some doctors managing to work with the insurance you have to get some things covered to an extent. Not positive if that is true with top surgery as well or not. It also has to do with working with the wording of the plan and basically wording things just the right way on the claim that they cover it. No idea how many doctors are willing to do that, however, because while I'm one who enjoys finding loopholes in how things are worded it's also a tricky game to play and I don't know if that might be risking insurance fraud or not.

That said, I agree with Rob that contacting your insurance company should be your first step in figuring out whether there is coverage available or not.

[Linus]

Hrmm.. Interesting, Noah. Mine doesn't have an explicit exclusion (unlike when we had Blue Cross/Anthem, which explicitly called out SRS as an exclusion) and I had called them about it before. The rule of thumb is this: http://www.aetna.com/cpb/medical/data/600_699/0615.html That said, it's the actual act of finding the right doctor that worries me. Given the importance of this and knowing who is good but not associated with an insurance provider makes this a bigger challenge (at least to me -- as a Canadian this process strikes me as counter-intuitive but that might be a different post/thread discussion)

I know of some doctors (in NYC) who will do it as a preventative breast cancer treatment and thus get it covered like that.

[Noah G.]

I'll have to look at that more closely when I'm not watching the clock...the language is kind of confusing to me though, but that could be because I'm paranoid about what time it is and that's distracting me. Might have to pass it on as well.

Unfortunately I can't help much with your actual worry, but wanted to chime in with my own experience just in case it offered anything useful.

Are you able to travel for this at all? Or does it have to be in the L.A. area? Just asking as I'm sure someone else might ask as well.

[wheat thins are delicious]

If your insurance will not cover SRS but you are still legally listed as female you could qualify for breast reduction and some surgeons are willing to reconstruct your chest in the manner you would like.  As in remove all breast tissue and make a male chest. 

[Linus]

I'll have to look at that more closely when I'm not watching the clock...the language is kind of confusing to me though, but that could be because I'm paranoid about what time it is and that's distracting me. Might have to pass it on as well.

Unfortunately I can't help much with your actual worry, but wanted to chime in with my own experience just in case it offered anything useful.

Are you able to travel for this at all? Or does it have to be in the L.A. area? Just asking as I'm sure someone else might ask as well.

Oh I can travel but I'd rather be closer to L.A. since post-recovery would be easier at home and my g/f can help me with that.

[Linus]

If you're able and your surgeon does not accept insurance as payment, you can pay the surgeon up front and then submit a claim to your insurance for reimbursement.

The only surgeon I've heard about accepting insurance as payment is Dr. Hazen in NYC. There are probably a few others, but I haven't heard of them. However, surgeons may be only willing to do this for certain insurance companies with which they have agreements.

I was going to do it with Dr. Hazen when I was out there but I never was able to followup with her after I had a BR-A (breast cancer gene screen) done.