First Endo appointment and insurance won't pay - What to do?

[jkm]

I thought I was good when I found a trans-friendly Endocrinologist that was in-network with my insurance (Cigna).  I went to the appointment, she prescribed me HRT, and a follow-up appointment was scheduled in 4 months.

 

Now, a week later, I find out my insurance won't pay a dime. citing reason: "Diagnosis Or Service Code Reported Not Covered"  I now have to pay the full $311 out of pocket for the visit.

 

But what's even worse is I don't know what to do now going forward for my care?  Going back to see her every 4 months and eating the full cost of the bill each time is not an option. 

 

What's the best option here to get affordable care?  Check with my Primary Care doctor, or maybe Planned Parenthood?  Wouldn't my insurance reject those as well for the same reason?

[Vidanjali]

@jkm Cigna does cover some gender affirming care, but it needs to be documented in a specific manner for it to be covered. You should be able to see the claim your endo submitted with diagnosis code in your online Cigna portal. You can also discover which diagnosis codes are required for which treatments in the pdf linked below, but it may vary from policy to policy. Therefore, it would be best to examine the pdf and then call to discuss with a Cigna representative who can confirm. It may just be a matter of finding out exactly which diagnosis code is required for the treatment your endo prescribed, and then working with that doctor to submit a corrected claim for your visit with an updated diagnosis code. 

 

https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/mm_0266_coveragepositioncriteria_gender_reassignment_surgery.pdf

 

If your endo for some reason is not compliant in working with you to submit a corrected claim, then you could find out from Planned Parenthood how they determine diagnosis codes when insurance is involved before your visit so you don't encounter surprise charges. 

[Carolyn Marie]

JKM, please don't despair.  Denial of medical insurance claims and prescription denials is very common, and my experience has been that it's an issue that can be quickly corrected.  @Vidanjalihad some excellent suggestions for you.  There is also something called "prior authorization," a method that insurers use to control costs.  It requires a doctor to jump through a couple of hoops to get your medicine approved.  The doctor should be very familiar with it.  Please work with him/her to resolve this.  Good luck!

 

Carolyn Marie

[jkm]

Small update:

 

Long story short, after calling my benefits administrator and my doctor's office, the issue really comes down to the reason code - they probably used one related to Gender Dysporia, and apparently my insurance doesn't cover that.  I have to wait for the actual bill to get posted, not just the initial explanation of benefits electronic form.  Once that occurs, I will call the billing department again and see if by some rare chance they can switch to different code that may be covered.  Although, who knows what code that even is (That link above doesn't tell me any about endo/hrt appointments).

 

I don't anticipate success with the above, so I think my next step to is call my doctor's office and see if I can skip the actual follow-up appointments and instead just do the updated blood work.  If that comes back good, then can they just update my prescriptions?  Perhaps a long shot, but worth a try.

 

 

[KatieSC]

I was just looking at Cigna's transgender health coverage as my employer is in the process of switching us to Cigna. I find it interesting that Cigna's policy is severely outdated despite their mention of World Professional Association for Transgender Health (WPATH) standards version 8.0. They mention having an assessment by a mental health professional, as well as taking into account real life experience in the desired role. That is so 1970s/1980s. There is no requirement under WPATH guidelines to have a mental health evaluation, unless there are underlying mental health issues. See link to Cigna policy: https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/mm_0266_coveragepositioncriteria_gender_reassignment_surgery.pdf

 

Although I have had my vaginoplasty, it makes me cringe thinking about how messed up Cigna may be as my future insurer. 

[KatieSC]

The other thing I meant to mention is that the primary care provider can prescribe and monitor your HRT if they feel comfortable. Endocrinology is not mandatory.

[jkm]

Well I recently got even more bad news after having my blood work done.  I logged into my account and nearly fell out of my chair when I saw they're going to bill me $800 for that!  So between that and the Doctor appointment, I owe $1,111 all out of pocket...insurance won't cover a dime.

 

I really regret not picking up the phone and calling these places beforehand to verify costs.  I just assumed my insurance was going to have my back, and I got burned big time!  A lesson learned.

 

I won't be doing that again!  I went ahead and called Planned Parenthood, and they quoted me a more reasonable $312 for the initial visit (which includes blood work), and $104 for follow-up visits that are doctor only.

 

On 12/2/2023 at 10:24 AM, KatieSC said:

The other thing I meant to mention is that the primary care provider can prescribe and monitor your HRT if they feel comfortable. Endocrinology is not mandatory.

Thanks for the tip.  I'm definitely going to check on that.  How wonderful it would be if I could just pay my $30 co-pay without my insurance weaseling their way out of paying.  There's so many loop holes and exclusions.  I guess it all depends on the ICD code they use to bill the visit.

[emeraldmountain2]

@jkm

 

I hope you find a way to get your insurance to cover this. Maybe don't give up just yet. I don't think they can deny your claim on the basis of gender identity or gender dysphoria, but I could very well be wrong.

 

If it turns out insurance really won't cover this, then ask the doctor's office or hospital to lower your bill. They may very well do so. What insurers actually pay doctors/hospitals and what a self-pay patient without health insurance will be billed can be quite different, with the self-pay patient's bill appearing higher until they call the provider's billing office's "bluff" out.

 

https://www.healthcare.gov/transgender-health-care/

 

https://money.usnews.com/money/personal-finance/debt/articles/how-to-negotiate-your-medical-bills