I'm a little confused reading Aetna's policy.

It says breast implants are considered cosmetic unless it is medically necessary.

I went onto the WPATH.org website and it says that breast implants are medically necessary for Transgender people. Has anyone gotten breast implants covered through Aetna?

"Medically necessary sex reassignment procedures also include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient (including breast prostheses if necessary), genital reconstruction (by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, penile and testicular prostheses, as necessary), facial hair removal, and certain facial plastic reconstruction as appropriate to the patient.

"Non-genital surgical procedures are routinely performed... notably, subcutaneous mastectomy in female-to-male transsexuals, and facial feminization surgery, and/or breast augmentation in male-to-female transsexuals. These surgical interventions are often of greater practical significance in the patient's daily life than reconstruction of the genitals." [3]

The medical procedures attendant to sex reassignment are not "cosmetic" or "elective" or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. [4] Further, the WPATH Standards consider it unethical to deny eligibility for sex reassignment surgeries or hormonal therapies solely on the basis of blood seropositivity for infections such as HIV or hepatitis.

There's been several threads throughout the years that had talked about this, especially the GRS & Insurance thread. In a Nutshell, as GRS becomes included on more corporations insurance options, some companies are thinking forward and including top surgeries with bottom surgeries. BUT even though the big insurance companies (Cigna, Aetna, United, Blue Cross, etc...) have made panels and determined a structure on how to proceed for trans clients, the employers buying the plans to offer to you must opt in to such services first.

With that said, When an employer opts in to gender corrective services, you have to first select a plan that covers it, then  go through a pre authorization process with a case manager to get things scheduled. If the plan covers breast augmentation for the transgender client, it will be filed under the same coding as if you had breast cancer and deemed medically necessary, instead of as an elective surgery. Elective means going to any cosmetic surgery center and going "oh my boobs aren't getting enough attention- can you make them bigger?"

So, what it means is that anyone who is applying for breast augmentation because of removing cancerous material, maiming/disfigurement, or (now) are trans and HRT did not provide adequate growth will be covered by insurance.

What veritatemfurto said.  However, I'd add that Obamacare may make changes as of January 1, 2017.  Three weeks later, a new President could make all sorts of other changes, though. 

Quote from: Colleen M on June 01, 2016, 11:22:55 AM
What veritatemfurto said.  However, I'd add that Obamacare may make changes as of January 1, 2017.  Three weeks later, a new President could make all sorts of other changes, though.

actually, the effort to make insurance more inclusive started back during the first Clinton presidency... we made a whole lot of progress since then- even during Bush Jr. It has just become more well known since Obamacare. Just wait for HillaryCare 3.0... Now the effort is to get all insurance packages to cover the whole package since it all costs less than a C-section anyways. The effort is a corporate one, so even if things go south politically, things will just be slow like they were under Dubya.

Quote from: veritatemfurto on May 31, 2016, 11:50:10 PM
There's been several threads throughout the years that had talked about this, especially the GRS & Insurance thread. In a Nutshell, as GRS becomes included on more corporations insurance options, some companies are thinking forward and including top surgeries with bottom surgeries. BUT even though the big insurance companies (Cigna, Aetna, United, Blue Cross, etc...) have made panels and determined a structure on how to proceed for trans clients, the employers buying the plans to offer to you must opt in to such services first.

With that said, When an employer opts in to gender corrective services, you have to first select a plan that covers it, then  go through a pre authorization process with a case manager to get things scheduled. If the plan covers breast augmentation for the transgender client, it will be filed under the same coding as if you had breast cancer and deemed medically necessary, instead of as an elective surgery. Elective means going to any cosmetic surgery center and going "oh my boobs aren't getting enough attention- can you make them bigger?"

So, what it means is that anyone who is applying for breast augmentation because of removing cancerous material, maiming/disfigurement, or (now) are trans and HRT did not provide adequate growth will be covered by insurance.

Thank you so much for your reply! So I just called Aetna and they said it will be covered 100% if my doctor deems in medically necessary and it will then be reviewed.

So my question is, how do I go about this? Do I ask my doctor to call them and tell them it's medically necessary? Also how does my doctor deem it as medically necessary? She is a trans doctor and deals with a lot of trans patient. Just because I'm transgender does she automatically say it's a medical necessity? 

Thank you!

Quote from: nikkxo on June 01, 2016, 04:23:32 PM
Thank you so much for your reply! So I just called Aetna and they said it will be covered 100% if my doctor deems in medically necessary and it will then be reviewed.

So my question is, how do I go about this? Do I ask my doctor to call them and tell them it's medically necessary? Also how does my doctor deem it as medically necessary? She is a trans doctor and deals with a lot of trans patient. Just because I'm transgender does she automatically say it's a medical necessity? 

Thank you!

always welcome!

It sounds like what they want is a letter from your doc on the matter, just like bottom surgery but without the other requirements. If your doc is trans too, then they should know how to twist the ropes in your favor and get everything worded correctly to send to the Nurse Case Manager (NCM) at Aetna. They are the representatives for your company that will handle the paperwork part of the surgical process. Most of the time, you'd have to ask specifically for the NCM- they are higher up than the regular reps that handle the phones and email. HR should know who your NCM is at the insurance company. Once that's established, the NCM should be able to give you a list of names to evaluate who would be the best choice for you.

Keep us in the loop, a lot more of us will be following in your footsteps

Quote from: veritatemfurto on June 01, 2016, 08:51:26 PM
always welcome!

It sounds like what they want is a letter from your doc on the matter, just like bottom surgery but without the other requirements. If your doc is trans too, then they should know how to twist the ropes in your favor and get everything worded correctly to send to the Nurse Case Manager (NCM) at Aetna. They are the representatives for your company that will handle the paperwork part of the surgical process. Most of the time, you'd have to ask specifically for the NCM- they are higher up than the regular reps that handle the phones and email. HR should know who your NCM is at the insurance company. Once that's established, the NCM should be able to give you a list of names to evaluate who would be the best choice for you.

Keep us in the loop, a lot more of us will be following in your footsteps

Awesome, Mel! 

I have an appointment with my doctor this coming Wednesday so I will ask her how to go about it. Unfortunately she is not trans herself but deals with majority of trans patients so I'm hoping she has done this in the past for a patient.

Will it be as simple as her writing a letter to them? I think they ask that she contacts the Patient Precertification Department, whatever that means.

Ugh, I hate dealing with insurance companies.

Patient pre-certification Department? That sounds like what my Cigna insurance called the Procedures Pre-authorization Department...

Getting through the paperwork process is the hardest part about surgery via insurance. Just make sure they understand to say need instead of want if you get what I mean. The wording makes ALL the differece, like in 2011 when i
used the newly formed loophole of getting a passport with the correct gender on it to get a corresponding license while pre or non-op in my state that wouldnt honor my previous license that was correct because of the rules change requiring two gov docs for issue while my birth cert was still wrong. I got it all done but the passport was issued as temporary one all because my doc at the time wrote the letter as "in the process of primary transition" (i.e.RLE) instead of "has completed primary transition" (i.e. as far as the process can go without surgery)

If there are any men reading this that have had top surgery via insurance, it might be helpful if they can provide any Insight too. From what I can guess, it would be the same process- just adding breasts volume instead of reducing them...

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