My insurance unexpectedly sent me partial reimbursement for top-surgery

The title says it all, but here’s the details:  Prior to surgery, I put a lot of effort into trying to figure out what I might be able to get reimbursed for.  I was on the phone with customer service for a long time one day; I scoured my insurance’s webpage; I tried to figure out codes and what they mean; my therapist called multiple times on my behalf.  I oscillated between feeling hopeful I might get partial coverage, and being convinced that there was no chance.

Ultimately it seemed like there was no chance.  I found a promising document at one point called, “Gender Reassignment Surgery Medical Policy,” followed by criteria to prove it is medically necessary.  Then I was told that that applies to some insurance policies with my insurance company, but my particular policy excludes this coverage, and that was the bottom line.

Still, people told me that it’s against the law to deny coverage, on a state by state basis, and my state should cover it.  I paid out of pocket, first for the surgeon’s fees in advance, and then for the surgical center, the day of.  After the fact, I asked my surgeon’s office to send me an itemized bill of what I’d paid for, and I submitted that to my insurance company, without much hope.  I figured it’d get denied, then I’d appeal and take it as far as I could.  Maybe I’d get some advice from my local gay alliance, etc.

About 2 weeks later, I got a piece of mail.  I didn’t open it because I didn’t care to read the bad news.  My spouse and I were leaving for vacation last Wednesday, and I figured I’d better open it before we left.  In case there was some deadline for appealing it.  I opened it up, and it was a check for $2,800.09!!!!  I yelled at my partner about it, the excitement of it, which must have been jarring because I almost never yell.  What an amazing way to start our trip!

That’s 47% of the surgeon’s fees (including 100% of the accommodations – staying at the surgeon’s guest room!)  I really could not believe it – either the person on the receiving end wasn’t paying attention at all, or they knew exactly what it was and had some strong personal beliefs of what should get to be covered!!

Now I’m just deciding if I should also get an itemized bill from the surgical center and try to get more money back…  Maybe I don’t want to push my luck…

It really paid off to just try, even though I didn’t believe anything would come of it!

Here’s a post I wrote earlier on this topic:
In February, I wrote GID: exclusion for top surgery coverage