Not sure where to start but my daughter is fighting an appeal for facial feminization and she asked me for help. She has Anthem Blue Cross and her denial letter states that it has to be a medical necessity.  I am unsure how to approach the letter. They also an IMR form if we want to have an impartial review of this decision.  I want to ensure my daughter gets what she needs to help her.

Thanks in advance.
Mary mother to Emily.
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I am not an expert on insurance but to prove it's medically necessary would need one or more therapist letters depending on the requirements of the insurance company. A place to start is to ask the insurance for a list of the standards you must meet in order to qualify for coverage. It could include full time living, HRT or other milepost that must be met

Quote from: mafery on November 01, 2016, 05:02:43 PM
Not sure where to start but my daughter is fighting an appeal for facial feminization and she asked me for help. She has Anthem Blue Cross and her denial letter states that it has to be a medical necessity.  I am unsure how to approach the letter. They also an IMR form if we want to have an impartial review of this decision.  I want to ensure my daughter gets what she needs to help her.

Thanks in advance.
Mary mother to Emily.

I have that on my computer....  I'll post in the AM.  You can establish medical necessity. 

Hugs

Jen

Quote from: mafery on November 01, 2016, 05:36:01 PM
Not sure where to start but my daughter is fighting an appeal for facial feminization and she asked me for help. She has Anthem Blue Cross and her denial letter states that it has to be a medical necessity.  I am unsure how to approach the letter. They also an IMR form if we want to have an impartial review of this decision.  I want to ensure my daughter gets what she needs to help her.

Thanks in advance.
Mary mother to Emily.
Modify message

Mary

Welcome to the site.

You had originally cross posted this post(posting the same thing in more than one topic.). That is against the policies of this site. I removed the one in another member's post. It had been replied to and I moved the replies to this topic.

I cannot give you anymore advice than JLT1 and Dena have posted.

However, I also want to share some links with you. They are mostly welcome information and the rules that govern the site. If you have not had a chance to look through them, please take a moment to:

• Site Terms of Service and rules to live by
  
• Standard Terms and Definitions
  
• Post Ranks (including when you can upload an avatar)
  
• Reputation rules
  
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Once again, welcome to Susan's. Look around, ask questions and join in.

With warmth,

Joanna

http://www.tsroadmap.com/physical/face/FFS-01.pdf
This has a good breakdown on the social acceptance aspect of ffs, as well as the clinical differences in regards to bone structure and irreversible effects of testosterone.

You should be able to comb through that PDF for many of the explanations and examples you will need.

When dealing with any sort of medical necessity and especially with care that is not typically covered you need letters of recommendation, and letters of necessity.

The other aspect is in regards to escalation of care. For instance you need to be able to document a timeline, what has been tried and for how long. Professional opinions on what could reasonably be expected if your daughter stays on her current course (for example x amount of time on hormones have achieved maximum feminizing effects, and the gap can only be closed through surgical means). You then need to prove that harm is being done to your daughter by not having access to ffs. This may include emotional incongruity, the lack of social acceptance (being able to successfully live in the chosen gender role) as well as any adverse effects such as anxiety, depression, social anxiety etc.

Probably at this point you may want to point out the physical differences in bone structure, as well as a recommendation of suggested procedures (the nitty gritty breakdown of each ffs procedure and how/why it will help and is required to close that gap).

You may need to provide photos of bone structure, as well as the current state of your daughter's facial structure.

You might be able to get a referral and consult to a plastic surgeon covered.

The key is going to have a team of professional advocates that can show the very real harm of not having the procedure as well as how and why FFS is the best appropriate treatment, and is necessary. (Vs any lower cost options).

I say have a team, as the willingness to provide documentation, letters and recommendations, as well as the openness to field questions from the insurance company and stick with you through the various appeals is going to be extremely helpful.

Remember that even though wpath does not dig into this area enough to cite them on necessity, getting the right doctors and therapists (with the right background and expertise to be a subject matter expert) is a viable path.

Remember the 3 D's of insurance
DEFER
DENY
DELAY

Insurance companies are counting on the fact that 99% percent of patients will give up out of frustration, and the delays in getting coverage.

You can beat them if your willing to become a professional hoop jumper and don't give up.

------

About my background

Not related to my gender transition I have a series of extremely rare conditions where documentation and clear direction of proper medical treatments is unavailable. I have successfully navigated the healthcare/insurance system and have been able to get coverage for extremely costly treatment ls and procedures that are almost never covered. The technique described above is applicable to any rare condition.

Good luck!
Brooke

The information and advice you've been given above is all excellent. I will add one more thing - be sure that you keep a very detailed journal of every insurance encounter, meaning dates and people and a summary of what occurred. My personal experience with Blue Shield (California) was that they were not adhering to specific rules and procedures - for example, timelines, format of appeal, etc. These are all simple ways to get the company in trouble, and believe me the arrogance of the players you will deal with will most likely lead them to step in sh*t along the way.

I am embarrassed to say that due to my own discomfort and insecurity with being trans, I was unable to fully grasp the harassment and prejudice that I was enduring at the hands of the insurance company. It was a blessing in disguise, as was the fact that they were not following protocol and that ultimately led me to (somewhat timidly) call the State Insurance Department to ask if there was anything that I could do. The State immediately assigned an attorney to the case because of the numerous, obvious violations. As far as I know there were several monetary fines and penalties levied against BS.

In my case, once the State became involved I no longer trusted anyone from BS. Do not fall for the "Patient Advocate" bs, no one is your friend in insurance - you are nothing more than dollars and cents.

In the end, I was reimbursed 100% for my surgery. I paid out of pocket first because my transition became more important to me than money, frankly, and I was correct that this surgery (for me) was worth the loan. The letter that advised I would receive payment in full had a very clear sentence that stated the payment was for my case specifically and that the procedure was "not medically necessary."

Good luck!

Mia

Hi,

Below is the basic information needed for FFS and then a copy of MY appeal letter with additional information from WPATH. 

Basic requirements:

1.  A letter of recommendation from my primary care physician.  The form and requirements of a WPATH recommendation for SRS from a psychologist had to be followed.  In addition, the letter had to address my physical health and any possible undo risks of surgery.

2.  A letter of recommendation from my psychologist, following WPATH SRS standards (copy in the "How I got FFS paid for by Insurance" thread).

3.  A letter from the surgeon stating what was being done and why as well as a letter under the WPATH guidelines for a psychologist recommending SRS. (Yes - same as for SRS, just change to FFS)

4.  A plan, from me, detailing my journey to becoming a woman, including dates for milestones:  When I started with my psychologist, when I started HRT, when I started RLE, when I will be changing my legal name and gender (with court appointment documentation), when I will have SRS (with letter from surgeon documenting date).

5.  The surgeon (Dr. Z) was also kind enough to provide legal references to two court decisions stating that FFS was a medical treatment for GID and not a cosmetic surgery.  Dr Z also provided them with recognized insurance codes for the treatment. (These two items were critical.)

Overall, most of this is needed for SRS, from the surgeon or for the actual transition.  The only additional item was the letter from my primary care physician.  I called and called and finally found someone who worked with me.  She was fantastic.  No, it was not fair.  Now we know, now we can make it easier for those who follow and perhaps, those who have already transitioned.

My Appeal letter:

"My Address and Insurance Information


                  My Insurance Company Address

Date

RE: Appeal of Coverage Decision regarding the Co-Pay Amount, Expedited Determination or Fast Coverage Decision requested

To Whom it May Concern:

Please consider this fax to be a request for an expedited determination of the appropriate benefit level coverage (out of network 55% benefit level approved, 90% benefit level requested) for all procedures referenced in Attachment A "Precertification letter from Dr Mark L. Zukowski for facial feminization surgery".  All procedures requested were either covered without precertification or were approved under Authorization # 35511881 (Attachment B). 

The request is for facial feminization surgery (FFS) under the "gender reassignment surgery" coverage criteria was supported by Dr XXXXXX, Psych Ph.D. XXXXXX and Endo XXXXXX (all in-network Providers).  All other requirements for the surgery were met as well.  FFS is a unique area of practice whereby the surgeon alters male facial features to bring them closer in shape and size to typical female facial features.  For many transgendered women, FFS is medically necessary to treat gender dysphoria and can be just as important, if not more important than genital surgery.1,2   

Quoting from the letter from Dr Zukowski (Attachment A) "As you know, these codes are the best match for what is required for the feminizing part of the operation." The codes are "best match".  Codes specific to FFS are not available.  However, no doctor within the Health Partners Network offers FFS although they may provide service covered under a certain code. Therefore, this letter requests that the in network coverage level be extended to all Dr. Zukowski's procedures.


"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.   Furthermore, not every patient will have a medical need for identical procedures; clinically appropriate treatments must be determined on an individualized basis with the patient's physician.

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."  WPATH Medical Necessity Statement, June 17, 2008


                  Sincerely,


Hugs

Jen

Hi Jen,
Do you have those legal references at hand or in your thread? As well as are those billing codes also available?

Thx for the great post!


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Quote from: Brooke on November 03, 2016, 12:37:40 AM
Hi Jen,
Do you have those legal references at hand or in your thread? As well as are those billing codes also available?

Thx for the great post!


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Insurance codes and costs used that covered my FFS:

ICD9         302.85   Endoscopic biplaner browlift with frontal bone and supraorbital bone burring with corrugator and procerus muscle disruption scalp advancement
   
CPT    21137   Endoscopic assist 3 dimensional reduction of orbital rim bone and frontal bone via high speed burring   $7,000.00
CPT   14041   Adjacent tissue transfer for scalp advancement   3,000.00
CPT   15824   Rhytidectomy; forehead with elimination of corrugator and procerus muscles   2,500.00
     
Primary feminizing rhinoplasty and septoplasty with inferior turbinate infracture   
CPT   30410   Rhinoplasty primary; complete external parts including bony pyramid, lateral and alar cartilages and/or elevation of nasal tip    7,000.00
CPT   30520   Septoplasty with submucous resection   2,000.00
CPT   30930   In-fracture of inferior turbinates   2,000.00
     
Full feminizing facelift of skin, SMAS plication and corset platysmaplasty with internal suspension sutures
   
CPT   15828   Minimal scar rhytidectomy of lower cheeks, chin and neck   7,500.00
CPT   15829   Superficial SMAS plication   2,000.00
CPT   15825   Platysmal flap of neck   4,000.00

     
Chin feminization with three dimensional bone contouring and reshaping of chin soft tissue
   
CPT   21209   Chin bone 3 dimensional endoscopic assist reduction via high speed burring and soft tissue reshaping   4,500.00
      Trachael shave   
CPT   31750   Tracheoplasty, cervical   5,000.00
CPT   21195   Bilateral reconstruction of mandibular rami and body with bone contouring via endoscopic assisted high speed burring   7,500.00
CPT   21296-50   Bilateral intraoral reduction of medial masseter muscle   3,000.00
CPT   40652   Vertical lip lift   3,800.00
CPT   20926   Harvest of fat tissue grafts fat grafting (50cc) to temples, lips, cheeks, nasolabial folds   1,250.00


I had the references for the decisions on my computer but I have been unable to find them.  Someone posted something about this in the "How I got insrance to pay for FFS" thread..

Hugs,

Jen