Medically Necessary?

[haigha]

Okay, so I found out that my insurance at Kaiser will cover my top surgery completely so long as it's considered medically necessary. I don't know much about corporate policies, so I guess I have to ask, what makes needing top surgery considered medically necessary? As far as I know, the only thing is if I had breast cancer, but there must be other

Comments

[icarus_after]

the only way to learn how kaiser defines medical necessity is to look at kaiser's policies or talk to a kaiser representative. other guys here can tell you what their experiences have been, but you need to get first hand information. when you talk to someone at kaiser, write down the person's name and the date you spoke with them, and what they said. you may need to reference it later.

are you insured as male or female? that will make a difference in determining medical necessity. if you're insured as female, it's possible you could have it covered as a reduction.

the AMA recently issued a resolution confirming the medical necessity of transition related surgeries. the irs recently declared transition surgeries to fall in the realm of deductible medical expenses, which is to say, not cosmetic. step one is to call kaiser and ask them what documentation you need to show medical necessity. it may be as simple as getting a letter from your shrink and one from your GP.

[ezraisabear]

Disclosure: I am a current law student but have experience working with insurance policies personally as well as helping friends (one of whom posted about his experiences last week in this community) and very briefly working with student health on their insurance policy while in undergrad

[haigha]

^^;; See my post about 4 posts down from here.. Because I'm an idiot who doesn't know how to use live journal properly.. ^^;;;

[ezraisabear]

Sorry I meant the above message to be directly posted to the OP. Apologies!

[mountain_man08]

My experience with Kaiser is that they covered a reduction surgery due to being a size D and it causing me health issues. The first doc I went to refused to do the surgery, saying I didn't qualify- But then I found another doc who was totally okay with it. He didn't know I was trans, and at the time I didn't think he would do it if he knew.

I went from a D+ to a small B, which made binding a lot easier. Then I saved up and went to Brownstein to do the rest.

[prettyboicris]

I would see which surgeon takes Kaiser that you are interested in going to. If you are listed as male you may be able to get it covered under Gynecomastia, If listed as female probably a reduction (Though the surgeon would remove everything) or a Prophylactic (preventative) mastectomy. Another way to get it covered is simply as a transition related surgery if your insurance has this rider. Check on the website for you insurance or ask them for the "policies"

Best of luck

[haigha]

Unfortunately I don't really know much about the coverage I have at all.. I live in Cali, so my insurance is from there. Southern california to be exact. I'm listed as a female. I was basically just told 'if it's considered a medical necessity, it would be covered, for example, if you had breast cancer, it would be covered'. I grew up relatively sheltered, so even though I'm 23, I don't know anything about insurance, or loans or anything of that sort to fund my own transition aside form paying completely out of pocket

[pirate_poet]

Hey, just letting you know unless you respond to someone else's comment (click "reply to this") directly, which sends it to their inbox, it's unlikely they'll see your comment here-- unless they scroll through all the comments on your post.

[haigha]

Oh.. See, I didn't even know that... XD I thought since I was replying to what a few people said, I should write an entirely new post or something so everyone sees it...

[meegosh]

I wish I was as small as a double D and as tall as 5'3".

I don't have definite answers for you. But I would suggest finding out some of the answers for ezraisabear. Your insurance isn't magic and the answers are there. Is your insurance via your parents or are you paying for it yourself? if it's your parents could you ask to have a look at the policy? If its yours then you should have a copy of the paperwork (you do save paperwork like that right?). That should have some of the answers so you can feed them back to ezraisabear.

[tazp]

Check the insurance company's website, mine had a wealth of information on it including what specifications deemed a breast reduction medically necessary. Companies are bound to vary but here is mine: http://www.aetna.com/cpb/medical/data/1_99/0017.html... )

[haigha]

I actually tried to explain to my primary physician yesterday that yes, I'm FTM, he knows that, but that's not what I'm hoping to do here. I tried to tell him I had a doctor I wanted to go to when I had the money to pay out of pocket in the future for 'cosmetic surgery' and right now I just want the pain gone so that I can work our comfortably and try to live a healthier more active life.... He claimed I wanted it for psychological reasons

[tazp]

Congrats - at least it is a start. Doctors are hit or miss from my experiance also. Finding one that is easy to work with can be a pain, but much easier in the long run that fighting them head on. Good luck.