I went to see my general physician 2 months ago for a referral to an endocrinologist.  It was a pretty basic visit that went something like:

Them:
"Let's check your weight, 150, alright."
"Let's check your blood pressure, looks good."
"Heart rate, looks good."
"So why are you here?"

Me:
"I think I'm transgendered and would like a referral to an endocrinologist."

Them:
"OK, let's see what we can do.  Oh my, it doesn't look like we can refer you without a therapist's letter.  Thanks for coming to see us today..."


So I paid my copay and went on with my life, started seeing a therapist, blah blah.

About 6 weeks go by and I get a bill in the mail from my doctor for the full amount of the visit.  I'm like, wtf?  Come to find out, my insurance denied the claim because the diagnosis was coded as "Gender Identity Disorder" and that isn't covered apparently.

It was a freaking general office visit where the dang doctor couldn't even help me, and I still have to pay for it!  Seriously?!

I spoke to the head of my HR department and gave her all the paperwork from the doctor and insurance company, but her attitude on the phone made me think that there isn't anything she can do, or will do.  Which isn't the impression I got from her when I came out to her a month ago.  It sounded like she'd do whatever it took to get me proper medical coverage, but now I'm beginning to question that. 

Gender Identity Disorder is archaic and from the DSM IV.  It should have been coded as Gender Dysphoria, as stated in the current DSM V.  Insurance will always try to weasel out of paying, so have doc resubmit with proper current coding.   

FWIW, my endocrinologist codes my visits as "gynecomastia" and "testicular hypofunction."  The insurance company pays, and I get a chuckle out of the fact that the diagnosis is really the prognosis. 

I just called and left a message with my doctor about possibly filing under the code for Gender Dysphoria instead.  I guess we'll see what happens.  Thanks for the advice!

Kristina,

Fingers crossed. I am prepping for that meeting too.

With warm thoughts,

Joanna

This is seriously frustrating to see, that insurance companies can deny treatment for a perfectly legitimate diagnosis. I'd start shopping around for one that won't.

On the subject of DSM, I don't have time to fact check currently, but my gender therapist mentioned to me once that most of the US codes in DSM IV because they were late to the party on DSM V and the government is asking that insurance companies and/or medical institutions code with DSM IV until DSM VI comes out, which they will then hopefully transition (hah) to. But again, total hearsay, so please take with a grain of salt. Whatever the case, I hope this gets resolved in your favour!

I don't know what DSM is, so i didn't bring it up in the message I left (haven't heard back yet btw, probably won't until tomorrow).  It's only one doctor's appointment so far that I've had to pay for, $116 total instead of just my $20 copay, but there will be plenty of stuff moving forward that they are likely to balk at if this is any indicator.

My HR department is still working on it too.  I figured I'd attack it from both sides since something needs to be done fundamentally for the long term as well as immediately.

Actually, I'd try to get your doctor to resubmit it as a general checkup, since that's what happened. You may have gone in for gender related stuff, but there was no treatment related to that given.

Short of them not covering something they previously said they'd cover (contract law), I don't think there's any way to fight this stuff outside their company. There's no regulatory or legal body that says they have to cover (or that healthcare providers have to provide treatment for) things the DSM or ICD or any other manual recommends as far as I know. Someone please correct me if I'm wrong.

And sadly in the US, as much of a wild-west scenario as it may be, and assuming you have money, we're still better off than a lot of nationalized healthcare countries who are still operating on disproven and outdated knowledge.