Susan's Place Transgender Resources

Hi, please excuse me if I post this in the wrong forum, and please excuse my english, I'm not a native english speaker. A few weeks ago my doctor asked for a referral and my insurance, which is Aetna HMO basic in California, denied it on the ground that (exact quote): "hair removal or hair transplant of skin resurfacing are considered cosmetic and are not a covered benefit under your plan". Normally I wouldn't have think twice about it, but this is electrolysis for SRS that I'm asking about. I don't know what to do because I'm barely even paying my bills and can't afford to do electrolysis without coverage. Is there anyway I can appeal the case? Have anyone have similar experience?

Have u tried groupon ?


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Welcome to Susan's Place. If your policy covers GCS, the surgeon should be able to write a letter indicating that electrolysis is a required part of the surgery. This link (https://www.susans.org/forums/index.php/topic,161778.0.html) will show you how a member was able to get their policy to cover FFS, something which is a bit more difficult than what you are attempting.

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I have had to deal with Aetna with this.  I have to appeal each time.  When they deny the claim, there is an address you can send the appeal to in the claim letter.  I include a cover letter, the claim letter and a letter saying it is medically necessary.  I have had some lucky, but it takes time.  Recently the last claim I had was denied before it was a claim, and I have had to submit it more than once.  In California you can file a complaint, which I hear helps significantly with:

http://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForm.aspx#.V79sRIUnE0N (http://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForm.aspx#.V79sRIUnE0N)

But I had not done so yet.

Quote from: Dena on August 29, 2016, 11:29:57 PM
Welcome to Susan's Place. If your policy covers GCS, the surgeon should be able to write a letter indicating that electrolysis is a required part of the surgery. This link (https://www.susans.org/forums/index.php/topic,161778.0.html) will show you how a member was able to get their policy to cover FFS, something which is a bit more difficult than what you are attempting.

I don't have a surgeon yet, the referral was referred by my primary care provider who is actually clueless about transsexualism and gender identity.  I will look into that.

I know for sure Aetna does cover SRS/GRS, so I guess I will figure something out.

Quote from: jessical on August 29, 2016, 11:38:07 PM
I have had to deal with Aetna with this.  I have to appeal each time.  When they deny the claim, there is an address you can send the appeal to in the claim letter.  I include a cover letter, the claim letter and a letter saying it is medically necessary.  I have had some lucky, but it takes time.  Recently the last claim I had was denied before it was a claim, and I have had to submit it more than once.  In California you can file a complaint, which I hear helps significantly with:

http://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForm.aspx#.V79sRIUnE0N (http://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForm.aspx#.V79sRIUnE0N)

But I had not done so yet.

That what I intend to do, if possible can you send me a sample of what to write to appeal? I'm not sure what to write other than "This is medically necessary and I'm only having hair removed FOR surgery"

Quote from: HiddenIdentity2 on August 29, 2016, 11:51:17 PM
I don't have a surgeon yet, the referral was referred by my primary care provider who is actually clueless about transsexualism and gender identity.  I will look into that.

I know for sure Aetna does cover SRS/GRS, so I guess I will figure something out.

That complicates matters a bit because if you are having PI then you don't need electrolysis. Scrotal flap may need it depending on the surgeon. A few think scraping is sufficient and don't want Electrolysis while others want a proper clearing  before surgery.

I am working through this with Medicare. I went with a letter from my therapist and citations on wpath necessity for permanent hair removal. The letter states something along the lines of "permanent hair removal is medically necessary for a successful social transition and as a prerequisite for GRS.

I took an itemized receipt from my electrolysis provider and accompanying icd10 (insurance billing) codes.

Other things that were in letter was diagnosis, past treatment, current treatments, and future treatment (grs).

I am going the reimbursement route so that might change your path.


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