Has anyone been successful in establishing medical necessity in PA, in particular with IBX (Independance Blue Cross)?

My first appeal was denied and I am putting the second appeal together, but submitted pretty much everything I could think of in the first go around.

You might have success if you have your doctor mention is necessary as part of treatment of severe depression, in relation to gender dysphasia.

I had success with getting FMLA approved for VFS this way.


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Quote from: Jill E on July 26, 2018, 01:20:15 PM
You might have success if you have your doctor mention is necessary as part of treatment of severe depression, in relation to gender dysphasia.

I had success with getting FMLA approved for VFS this way.


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Unfortunately not.

I have letters from two therapists, my personal physician who is part of the University of Pennsylvania's LGBT department, and the surgeon.

Additionally have the supporting passages from wpath as well as the codes and justification for each code.

And a letter from me describing the need in my own words.

Got denied twice, and I know others have succeeded with less.

Quote from: jill610 on July 26, 2018, 01:55:25 PM
Unfortunately not.

I have letters from two therapists, my personal physician who is part of the University of Pennsylvania's LGBT department, and the surgeon.

Additionally have the supporting passages from wpath as well as the codes and justification for each code.

And a letter from me describing the need in my own words.

Got denied twice, and I know others have succeeded with less.

Wow, I'm really sorry to hear that. [emoji853]


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Quote from: jill610 on July 26, 2018, 01:55:25 PM
Unfortunately not.

I have letters from two therapists, my personal physician who is part of the University of Pennsylvania's LGBT department, and the surgeon.

Additionally have the supporting passages from wpath as well as the codes and justification for each code.

And a letter from me describing the need in my own words.

Got denied twice, and I know others have succeeded with less.

Is FFS specifically covered in your pan, or is it excluded?  Mine (not in PA) specifically covers it and did not deny it on the first try.

Maybe right a letter to the surgeon general of PA and ask her to intervene.


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Quote from: ainsley on July 26, 2018, 02:00:49 PM
Is FFS specifically covered in your pan, or is it excluded?  Mine (not in PA) specifically covers it and did not deny it on the first try.

"Potentially cosmetic" so medical necessity needs to be argued to move from cosmetic to medically necessary and therefore covered.

I have submitted the "normal" documentation but getting blocked with "cosmetic because not a functional impairment".

Quote from: jill610 on July 26, 2018, 02:14:57 PM
"Potentially cosmetic" so medical necessity needs to be argued to move from cosmetic to medically necessary and therefore covered.

I have submitted the "normal" documentation but getting blocked with "cosmetic because not a functional impairment".

I see.  I had this issue for approval of a rhinoplasty as part of my FFS because that is considered cosmetic unless you have documented breathing obstruction.  Asinine when my plan specifically states:

Generally, covered expenses include:
Facial feminization surgery (male to female), including but not limited to facial bone reduction, face "lift," facial hair removal, and certain facial plastic procedures.

They just deny automatically and it is incumbent upon us to prove our needs.  It is tantamount to discrimination, in my opinion.

Quote from: ainsley on July 26, 2018, 02:26:17 PM
I see.  I had this issue for approval of a rhinoplasty as part of my FFS because that is considered cosmetic unless you have documented breathing obstruction.  Asinine when my plan specifically states:

Generally, covered expenses include:
Facial feminization surgery (male to female), including but not limited to facial bone reduction, face "lift," facial hair removal, and certain facial plastic procedures.

They just deny automatically and it is incumbent upon us to prove our needs.  It is tantamount to discrimination, in my opinion.

How did you get past that hurdle?

Quote from: jill610 on July 26, 2018, 02:27:38 PM
How did you get past that hurdle?

I got a documented breathing problem put into my record (deviated septum).  It was easier to play their game than explain to their hard heads that a it is a non sequitur to approve FFS for a MTF and deny a rhino to address a male nose on a female face for a MTF.  It is just so illogical!! 

An update here,

So trying to follow a number of paths to get this approved simultaneously either through my insurance plan, through my employer or through, we will say, outside influence.

I received the latest rejection letter (appeal 1 denial) on 7/25 stating that "no functional impairment has been demonstrated". This was reviewed by 1 internal medical director and 1 external consultant specializing in plastic surgery. Ooooh so that last one caused me to ask if either of them have documented experience, expertise or certifications in the treatment of transgender patients such that they could have the background and authority to overturn the opinion of three certified physicians who wrote letters of medical necessity as well as the WPATH standards.

Of course the answer was "No, but you may request such qualifications in your next appeal".

I also asked, repeatedly for a copy of the standard or guideline used to make determinations of "Cosmetic" vs. Medically necessary when a code is listed as "Potentially Cosmetic". They resent me the policy itself (for the 3rd time) which does not contain such information.

Ok so blocked by insurance. bummer.

At the same time, I am going up the chain within my employer. Some folks in my upline suggest going straight to the top, however I do need some of the folks on the ground to help me on a daily basis with overrides for drug categories and such (I am getting Delestrogen at the generic price due to the perpetual backlog issue).

So I made it up to the HQ VP responsible for such things and her response was "follow the process". So I gave her the sob story... sorry, history, of my claim and how it has taken 8 months just to get to the first appeal. The process is broken.

Anyways, so the company will not do anything at this point. Maybe after all of the appeals are exhausted. Meanwhile HR continues to research options. However, they did manage to get assigned to me two resources outside of the company and outside of insurance to help file my claim (yay!, I think). One is a medical director for a private company who deals with submitting appeals and the other is a trans specialist. I am suddenly cautiously optimistic.

I submitted to them a small mountain of documentation:

• Original Submission to Insurance, including Diagnosis code (F64.0) and the numerous ICD codes
• Copy of the appeal denial
• Copy of letter I wrote as part of appeal
• WPATH conforming letter from therapist 1
• WPATH conforming letter from therapist 2
• WPATH conforming letter from physician
• WPATH conforming letter from Facial Team
• Copy of WPATH statement on medical necessity 12/21/16
• Copy of WPATH v7 standard
• IJT study on facial gender confirmation surgery
• Article on Bone Modification in Male to Female Transgender Patients
• NYT artlcle about efficacy of FFS
• Copy of list of BCBS health plans known to explicitly cover FFS as medically necessary (MA, ILL, TX for those counting)
  

Fingers crossed, hoping for the best. Expecting the worst.

So the current saga is around the concept of functional impairment, which still seems to be fairly vague.

Any suggestions on how to establish or demonstrate FUNCTIONAL IMPAIRMENT that is not psychological in nature that is remediate by FFS?

Lower face: has your dentist or an orthodontic surgeon observed jaw muscle issues too tight, teeth alignment and grinding?  MTF HRT without FFS should reduce masseter (jaw muscle) but your dental history might show the potential for other improvements after lower FFS. 

Upper face: any past issues with sinuses?  Chronic headaches?

I didn't involve this sort of thing but I have experienced a physical benefit from FFS.  I find it easier to play the violin.  After puberty I had a sharp bone sticking down from my jaw corners, always caused a bruise and soreness where my jaw bone contacted the chin rest on a violin.  After FFS that recurring bruise and moderate pain is gone.