MVP DENIED Coverage for SRS Surgery?! It states in our Plan that it IS covered!

[Guest Joyful Mama]

Well, I have spent considerable time doing my homework and determining that our MVP CDHP health care covers SRS MtF surgery. It will be considered out-of-network, and is supposed to be covered at 60%. I have spoken to them on the phone several times, have a case manager who told me it is covered, but, yet, today we received a DENIAL in the mail from them.

The letter states,' The medical reason for this decision is documentation supports that the procedure is intended to improve the member's appearance. Documentation does not support a functional problem that will be corrected with the requested surgery.' In making the decision to deny benefits, MVP relied on its internal Medical Policy Manual (Cosmetic and Reconstructive surgery.).

Of course we received the letter after 5 p.m. today so the health care and surgeon's offices are closed until Monday morning. I will have to be patient in waiting for Monday morning, but thought I would post this and see if anyone has had a similar situation receiving a denial, when, in fact, the policy does cover it.

I am wondering if the therapist letter didn't word it properly?!

I will begin the appeal process, but wondered if anyone can provide suggestions in having a successful appeal. Surgery is in June for my daughter so I need to move quickly.

Thank you!

Joyful Mama

[Carolyn Marie]

Geez, Mama, that's strange. Why would they have it listed in their plan if they considered non-covered cosmetic surgery.

I would certainly download and make a copy of the portion of the SoC that talks about the medical necessity of SRS/GRS. Another good document is the U.S. Tax Court decision concerning the deductibility of GRS/SRS as a medical expense. You can find that here: http://www.ustaxcourt.gov/InOpHistoric/odonnabhain.TC.WPD.pdf

Good luck.

Carolyn Marie

[Guest Fionnuala]

The resolution from the American Medical Association which called on health insurers to stop discriminating against trans patients may help as well:

http://www.tgender.net/taw/ama_resolutions.pdf

[Guest Joyful Mama]

Thank you, Carolyn and Fionnuala, for the links. I will look into including this information when I appeal! Wonderful info - thank you so much!

[Drea]

Some insurance companies routinely deny such things because the cost to them is virtually nil and if it doesn't get appealed they have made out like bandits. The key is that it needs to be "nedically necessary" and such has to be the recommendation from one's therapist. There can be other factors. Even when insurance companies exclude surgery, if it could be proven to be mecially necessary, sometimes they would still pay. Exactly what serves as such proof I can't say.

Good luck

[Guest Donna Jean]

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Oh my...I agree with both posts above....

G'luck

Dee Jay

[Guest BeckyTG]

Dr. McGinn will talk at length about the poor quality letters she gets from potential patients.

To assist those who may need help with this complex task, she has written up specific guidelines for what must be included in the letter, found here:

http://www.drchristinemcginn.com/services/socrequirements.php

Two letters are required, one from a therapist and an second one from a therapist with a Ph.D. The second may simply be a concurrence of opinion with the first, but it does have to be from a result of a personal interview.

It wouldn't hurt to compare what you submitted to what Dr. McGinn has outlined.

Time to do some homework and don't give up. Surgery DOES cure this terrible condition. I will attest that this is most certainly a medical condition, not a mental one. Nearly every post-op that I have met will say that, the minute their eyes opened after the surgery was performed, their mind was clear and the anxiety and conflict of GID was over. They were finally free to live normal lives.

All my best to you.

Becky

[Guest Joyful Mama]

Becky,

Thank you for your comments and advice! Dr. McGinn is our surgeon and her office submitted the paperwork to MVP and felt everything was in good order. In fact, they commented that the evaluations were perfect and exactly what they needed. Something seems wrong with this picture, doesn't it?! I will sit down and go through Dr. McGinn's requirements over the weekend again to be sure there isn't something that was missed. Monday can't come fast enough to begin resolving this issue with the health care.

Joyful Mama

[Bulldog1948]

Also, sometimes it's a matter of "codeing"

Mike