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