GID: exclusion for top surgery coverage

When I started moving forward with the process of getting top surgery, I did so with the assumption that I would be paying in full out of pocket.  My therapist had looked into coverage a while back, for me, and told me it was not covered.  Still, though, times are changing, and I had a sliver of hope that my insurance plan might have been updated.  In my state, government funded health care now fully covers transgender related treatment and surgeries.  Maybe mine would, by now, too?

Yesterday, I was on the phone with a customer service person for over an hour.  At first it seemed promising.  I gave her the category number – F64.1 (gender identity disorder in adolescents and adults) and the code for the surgery type – 19304.  She said, “Double mastectomy?” and I said, “Yes.”  She then proceeded to try to find out whether the surgeon was in network or out of network.  She told me that if she’s in network, I would be paying a total of $70.  If she was out of network, I would be paying a $750 deductible, and 80% would be covered beyond that.  I started to get my hopes up – either of those would be awesome! – but also remain skeptical.  The customer service rep made calls to my surgeons office, to the surgical center, and to some other places.  She determined in the end that it would be out of network.

At that point, I said, “OK, I just want to make sure you’re doing this through the category of gender identity disorder?  It is a gender-related surgery.”  She responded, with a blankness in her voice, “That’s an exclusion under your policy.”  I replied, as my heart sank a little, “OK so nothing will be covered.  So it doesn’t matter whether she’s in network or out of network?”  “Correct.”

I was mad that she overlooked the category I gave her, as a first piece of information, and moved forward as if there would be coverage, only to let me down.  And that once I made it clear, she didn’t have anything more to say to me that might be helpful.

I asked her about the appeals process.  She said I would pay for and get the surgery, the office would submit the claim, the claim would be denied, and then I could work toward getting some reimbursement.

I brought her attention to a 7 page document that is called Medical Policy, Subject:  Gender Reassignment Surgery.  It lists criteria that need to be met in order for a surgery to be deemed “medically appropriate.”  I asked her what this was, and what would happen if I gathered enough information to move ahead with this.  I told her it was difficult to understand exactly what I was reading.  She said she was reading along with me, and that yes, these policies are confusing.  She then put me on hold again, and when she came back, she completely derailed that conversation – she steered me back toward the exclusions.  She added that not only was the procedure excluded on the basis of gender identity disorder, it was doubly excluded because it falls under “cosmetic surgery.”  The conversation was basically over at that point.  I stayed on the line to complete a survey about the call, and I gave her good ratings because she was way more helpful (making multiple phone calls on my behalf) than I was expecting.

I keep going back to this medical policy document.  I don’t know for sure, but I have this feeling that it’s the loophole for filing a grievance.  That if I can prove it’s medically necessary, I have a shot at getting at least partial coverage.

However, the criteria are so extremely binary in nature.  Some examples

The patient has completed a minimum of 12 months of successful continuous full time real life experience in their new gender, with no returning to their original gender, including one or more of the following:
1. Maintain part or full time employment; or
2. Function as a student in an academic setting; or
3.Function in a community based volunteer activity

The patient has undergone a minimum of 12 months of continuous hormonal therapy (unless contraindicated)
I would have to have two letters from licensed health professionals, one of them being from a psychiatrist or psychologist (that part would be easy).  If one could be from a psychologist, and the other from a psychiatrist, I just might be able to put something together (with a little stretching of the facts…)  If one has to be from a doctor or other medical health related person, I may be out of luck…
I’ve had close to 3 continuouos years of HRT (although I am not currently on HRT, and I did not move into the opposite gender).  I’ve had 10?  12?  years of continuous real life experience, although it has not been full time.  It has been in my “new gender” even though that has not been the “opposite gender.”  There is nothing in there about having to legally change your gender or name (good).
I’m not sure how to proceed exactly – all I know is that it’s going to be worth a shot…

15 Comments on “GID: exclusion for top surgery coverage”

  1. The idea of deeming the surgery “medically appropriate” bypasses the designation “cosmetic”. A point to consider when arguing your point is that a rhinoplasty would be considered a cosmetic surgery under most pretenses, but if you consider that the patient was attacked or injured in some way, it no longer becomes a cosmetic surgery, but a reconstructive one. If you can prove (by way of medical consults) that your procedure is medically necessary for your mental health, it no longer should be considered a cosmetic surgery. Additionally, as most companies do not have in-network providers for such procedures, you can usually argue to have it covered as in-network for that reason. Good luck.

    Liked by 3 people

  2. Lesboi says:

    Thanks for sharing this with us. I’m going to be going through this soon too so it’s helpful to hear your experiences. My state just mandated that trans care can’t be excluded but I’m not sure if that will effect me or not. Keeping fingers crossed. Good luck!!!


  3. Caidin Smith says:

    I went through all of this too with my insurance, and the customer service people had no clue how to provide me with the answers I was looking for. So I spent hours and hours researching for myself. I have Anthem BCBS, and the wording in my explanation of benefits is extremely vague. It seemed like I’d read one section that made it sound like they’d cover everything, then come across something somewhere else that _____ is not considered medically necessary and is not included in whatever benefit. It was extremely confusing and frustrating. My primary care physician even called them to get more specific information and they told her the same thing. But my plan states that it covers gender reassignment surgery, and top surgery is considered to be included under that type of surgery as long as it’s deemed medically necessary. That was the key. For my surgery to be covered, I had to find an in-network surgeon, and get a letter of medical necessity from my therapist. The surgeon’s office had to submit a claim for preauthorization to my insurance company, and then it was up to them to determine whether or not they believed it was medically necessary based on the documentation provided. In all the research I did, I found a statement somewhere that stated that my insurance company goes by the 7th Edition of the WPATH Guidelines, which are updated and do not require the real life experience stuff or hormones to obtain top surgery. The 6th edition contains the guidelines you listed, so if I were you I would verify with your insurance which edition they base their criteria on. One of the surgeons I went to for a consultation who was in-network with my insurance still makes his patients fill out forms according to the old criteria, and I don’t meet any of them, and it was really frustrating being asked to answer questions like how many months of real life experience did I have living as the opposite gender and in what kinds of settings, and when did I start hormones and who prescribes them. None of that applies to me, and I felt like because he was going to be including that kind of information in his submission to my insurance company, it would prevent me from getting the surgery approved. This surgeon also charges a crazy “cosmetic fee” that he does not submit codes for to the insurance company. I had to ask them many times about this, because the surgeon is in-network and if the insurance company approves the surgery, then whatever my benefits state for coverage should be covered and that’s that, because they’re supposed to submit codes for everything they’re doing in the procedure. The whole point of the letter of medical necessity is to determine that the procedure is not cosmetic, so it makes no sense to me how he can charge a separate “cosmetic fee,” not submit the codes for it to the insurance company, and they wouldn’t be able to tell me how much it would be until after the surgery, ranging anywhere from around $2,000-$6,000 based on how much he thinks his work was worth, like how much artistic skill and stuff he had to use to recreate your chest. Once I got that information I started looking elsewhere. So even the surgeons themselves find ways to evade the insurance companies. The best piece of advice I can give you is to make sure you advocate for yourself and get all your questions asked. Make sure you know exactly what the surgeon is charging for, what codes they’re submitting to insurance, and if they charge the patient any extra fees out of pocket that are not submitted to insurance. You won’t have a definite answer until you go for a consultation and the surgeon submits all the information for preauthorization, and then you wait for an answer from the insurance company. The process is frustrating and way more complicated and confusing than it should be, but after all of this I found a surgeon who was in-network and did not charge any extra hidden fees. Also make sure that the surgical facility or hospital and the anesthesiologist that the surgeon uses are also in-network with your insurance because those are separate fees that you’d be responsible for if they’re out of network. Good luck!!

    Liked by 1 person

    • janitorqueer says:

      Thanks for sharing all this info! I’ve never heard of an additional cosmetic fee – that’s bizarre! If you don’t mind adding – did your insurance end up paying for it or for part of it?


      • Caidin Smith says:

        Yes they did! I went with an in-network surgeon (Dr. Melissa Johnson), and the whole thing was covered, with the exception of whatever copays/desuctibles I owed which were very minimal. This included the consultation, the surgery, anesthesia fee, surgical facility fee, and I stayed overnight in the hospital. They also took me back into the OR a second time after the initial procedure because I developed a hematoma that was actively bleeding and they had to go back in to fix that. So it ended up being like 2 surgeries. And my insurance has been sent the bills for everything. It was definitely worth all the research and everything I did on my own! Even though it was very frustrating and time consuming, it paid off!


  4. Amy says:

    Glad that this is becoming a reality for you!! Disappointing that this kind of surgery is considered “cosmetic,” though. I admire you for all the work you’re doing in terms of trying to get insurance to cover at least part of the surgery. Hope it’s successful! ❤


  5. Jamie Ray says:

    I had my surgery right before the ruling and was not covered by this. The hard part is getting the “medically necessary” designation. Your insurer should be able to tell you what kind of a letter is necessary (PhD or Psych MD) and you will have to jump through hoops for it. I gave up and paid out of pocket, which was not a hardship but still a lot of money.


    • janitorqueer says:

      Yeah, right now I aim to try, but I can kind of envision myself not following through and just paying… sort of like getting a new roof for the house: I knew there were grants out there (my friend kept pushing this idea on me), but I just paid for it in full because it seemed like too much bureaucracy!


  6. micah says:

    Insurance is extremely confusing, and props to you for navigating it this far. I recommend you file a grievance, even if after the fact – all you have to lose is time. In many cases they issue partial coverage, especially if you provide all the proper documentation. Just “pretend” like that phone call did not happen and you are entitled to the coverage.


  7. Good luck! It sounds very tricky and confusing, I hope it all works out.


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s