Road Blocks

I joke that like a finicky child insurance companies favorite word is “No!”

Most people have never advocated for themselves to fight an insurance company denial of coverage for  a medical procedure. I had a call from a trans person who was denied coverage for breast augmentation surgery, she said that they denied to cover the procedure because it is cosmetic.

Transgender Medicaid Patients Face Coverage Barriers Despite Law
Bloomberg Law
September 10, 2019

Recent lawsuits are directing states to include gender affirming surgeries in their Medicaid coverage and end a half-century of debate on directing taxpayer dollars toward transgender care.

A mishmash of state policies and a myriad of legal barriers still make getting coverage a challenge.

Seven states have policies in place barring Medicaid coverage for surgeries, despite a federal law that mandates the coverage. Many of these states, most recently Wisconsin, are seeing these decades-old laws overturned in court. Even in the 19 states with laws requiring Medicaid to cover transgender care—which encompasses over 20 different forms of facial, body, and genital surgeries—low reimbursement rates and the limited amount of surgeons make getting covered a challenge.

Yep. The insurance companies get to use their favorite word… No! Even when it is against the law.

One of the golden words your doctor can use is… “Medically necessary”

Iowa is a textbook example of the uncertainty insurers and surgery seekers face concerning coverage. The Medicaid coverage requirement in the state has flip-flopped position multiple times in the past year. First, it banned coverage. In March, a federal court struck down its ban. Then in May, Gov. Kim Reynolds signed a bill into law allowing Medicaid providers to opt out of coverage for the surgeries.

“This is an elective surgery that if Iowans want to do, that’s fine but not with our taxpayer dollars,” state Sen. Jake Chapman told the Associated Press as the bill was introduced.

“This is an elective surgery...” that is why the golden words are important for the doctor to use, to clarify that this is not elective surgery and it is important to our health and wellbeing.

Even with no basis for a denial, the roadblock of an appeal often prevents people from pursuing the surgery, Green said. “Most people give up.”

That is what the insurance companies are hoping that you give up, many do. Many don’t know how to appeal the rejection.

Insurers will often deny claims as a result of confusion surrounding the medical necessity of different procedures, according to Kieran Chase, a program manager at Basic Rights Oregon, a transgender justice center.

Some of the problems come from how doctors code the request for surgery. For example, electrolysis. Do you know how to gt it covered by the insurance companies?

If you try to get it covered you run right into the roadblock… its cosmetic, but it isn’t always cosmetic. Ever hear of Hirsutism?

Well the treatment for it is covered by insurance, the key for coverage is you have to be listed as female  on your insurance policy and your doctor has to code it as L68.0, you still will probably still have to fight it but you are now have a better chance of winning the appeal.

Our other problem is finding a doctor who takes insurance; many electrologist do not accept insurance so you have to put your money up front and try to get reimbursement from the insurance company. If you don’t have the money to cover it you are SOL.

So what did I tell the woman who wanted breast augmentation surgery?

I explained to her that it should be covered and how to go about appealing the insurance company denial, and directed her to websites that explain how to appeal denials for trans people.

Another roadblock is ERISA (Employee Retirement Income Security Act of 1974), so far there have been no definitive court ruling on coverage for us, so if the company that you work for is self-insured you might be in for a long legal battle and your best bet is to contact an organization like GLAD, Lambda Legal, or Transgender Law Center who may want to make a test case from your denial.

Here in Connecticut we have a state healthcare advocate who can help fight for your legal coverage. I have worked with him on the US Health and Human Services policy change denying us healthcare coverage.

Good luck.