Insurance will not cover implants

[ViaSwiss]

Anyone (needhelp & drjeep) have any updates?

I am in the exact same situation regarding being denied because its not "gender dysmoprhia".

Not sure what my first step should be. Going to see if Coloplast has some type of team that can help out. And ready to file an appeal.

What insurance companies tend to cover this treatment. I might have to wait until the next open enrollment and just switch plans.

[dg_moore]

It's generally not the insurers who will not cover implants. More often it's the employer who tells lthe insurers what to cover.

[ViaSwiss]

My policy is through the marketplace so not through my employer.

[PeteTx]

My ace-in-the hole was the fact I am employed by a federal contracting company. Any company that provides services to the federal govt or receives "any money" from the federal govt is subject to strict anti-discrimination regulations. If your market insurance plan is subsidized with federal funds they probably cover implants already. If they don't file an EEOC complaint. You just might win a monetary award in addition to the surgery. .

[newbie443]

My policy is through the marketplace so not through my employer.

Anyone (needhelp & drjeep) have any updates?

I am in the exact same situation regarding being denied because its not "gender dysmoprhia".

Not sure what my first step should be. Going to see if Coloplast has some type of team that can help out. And ready to file an appeal.

What insurance companies tend to cover this treatment. I might have to wait until the next open enrollment and just switch plans.

needhelp paid out of pocket as did I. There are plans for financial help available maybe through Coloplast. Not sure. I have an AMS LGX.

My market place plan is a BCBS Gold plan but they only cover physical injury or damage and require prior approval. They only pay if I was to use one of the doctors in my part of my state. My cost with insurance was in the ball park of 4-7 thousand. My plan has no out of area coverage unless life threatening injury or illness. Every state is different and controls health insurance. My state will be approving companies to sell insurance this fall. And policies will most likely change so you will need to wait till October or November to check. I can get you the section number and coverage statement from my policy if you like and you can call BCBS if they are approved to and sell insurance in your state.

If you have a really good local doctor I would go with him/her. If not and you want use one of the high volume docs they most likely have payment plans. needhelp had some info and was looking into it. You can check with the doctors you are considering for this and see if they have an cash price and financial plan.

If you'd like to talk just send me a PM and I'll get you my phone number.

[drjeeps]

I’m still fighting my insurance company. I’m on round two of the appeals process . I should know something hopefully this next week. I’m still hopeful we can get this resolved however I also know this could turn into a total battle.

[PeteTx]

The primary take-aways when your denied due to an exclusion:
1. The insurance company only provides the coverage your employer includes in their plan. The employer decides to add or exclude coverage above basic. FYI, post mastectomy breast reconstruction is mandated by federal law.

2. Penile implants are not mandated unless your company has contracts with the federal govt for products or services. Then they must obey the Federal Contract Compliance regulations and Presidential Executive Orders against sexual discrimination. Failure to comply can result in loss of all contracts, and/or blacklisted from future contracts, and/or fines.

3. However, if your insurance covers gender reassignment surgery they are guilty of sexual discrimination if they do not cover a penile implant when gender dysphoria is not an issue.

This is a redacted version of my ethics/discrimination complaint:

Ethics complaint text:

I am claiming disparate sex discrimination toward male employees covered under the "your company" Health Plan.

Our health plan explicitly excludes the coverage for an inflatable penile prosthesis for any and all conditions.

The exclusion states:

Sexual dysfunction/enhancement. Any treatment, drug, service or supply to treat sexual dysfunction, enhance sexual performance or increase sexual desire, including:

Surgery, drugs, implants, devices or preparations to correct or enhance erectile function, enhance sensitivity or alter the shape or appearance of a sex organ, and sex therapy, sex counseling, marriage counseling or other counseling or advisory services.

An implant is universally accepted as medically necessary to treat Peyronie’s Disease, post prostatectomy impotence, and physiological forms of erectile dysfunction conditions found only in males. “MY INSURANCE COMPANY “ has published a clinical guide covering sexual dysfunction for policies that provide this coverage. I understand the coverage denial for “enhancement.” I do not understand excluding treatment for injury or disease that applies to only men.

Coverage statement for transgender surgery:

Transgender (Sex Change) Surgery...

For genital surgical sex change, you or your dependent has undergone a urological examination for the purpose of identifying and perhaps treating abnormalities of the genitourinary tract, since genital surgical sex change includes the invasion of, and the alteration of, the genitourinary tract (urological examination is not required for persons not undergoing genital change), and You or your dependent has demonstrated an understanding of the proposed male-to-female or female-to-male sex change surgery with its attendant costs, required lengths of hospitalization, likely complications and post-surgical rehabilitation requirements of the planned surgery. The covered person has obtained precertification from Aetna. Covered expenses include: Charges made by a physician for: Performing the surgical procedure, and Pre-operative and post-operative hospital, office and home visits. Charges made by a hospital for inpatient and outpatient services (including outpatient surgery). Room and board charges in excess of the hospital’s semi-private rate will not be covered unless a private room is ordered by your physician and precertification has been obtained. Charges made by a Skilled Nursing Facility for inpatient services and supplies. Room and board charges in excess of the hospital’s semi-private rate will not be covered. Charges made for the administration of anesthetics. Charges for outpatient diagnostic laboratory and X-rays. Charges for blood transfusion and the cost of unreplaced blood and blood products. Also included are the charges for collecting, processing and storage of self-donated blood after the surgery has been scheduled.

The Aetna Health Plan covers the procedure for a penile implant for female-to-male gender reassignment surgery. A female can receive a penile implant to reassign gender while a male is denied the same device to treat injury or disease.

I am claiming discrimination based on sex as cited in the following:

EEOC COMPLIANCE MANUAL

CHAPTER 3: EMPLOYEE BENEFITS

TITLE VII /EPA ISSUES

II. Discrimination Based on Sex, Race, Color, National Origin, or Religion

B. Health Insurance Benefits

Like retirement benefits, health insurance benefits must be provided without regard to the race, color, sex, national origin, or religion of the insured. An employer must non-discriminatorily provide to all similarly situated employees the same opportunity to enroll in any health plans it offers. An employer must also ensure that the terms of its health benefits are non-discriminatory. In evaluating charges that an employer has discriminated in the terms of health benefits it offers, the following principles apply:

The employer cannot provide different coverage to men and women where the risk insured against is mutually contractible - that is, where the underlying condition affects, or the treatment/test is available to, both men and women.

Where both men and women are, or could be, affected by the same condition or helped by the same treatment, the employer will be liable for sex discrimination if it provides different coverage to employees of each gender on the basis of gender.

[Piddlin]

Not certain what your plans are if you can't get insurance coverage. I did not have the coverage and had to go out of pocket.
Check out the folks at Surgeo.com . I used them and they brokered everything and at a reasonable price. Got mine done for $20k. Only extra was my hotel stay and gas to drive to Huston.

Best of luck,
Piddlin

[Blankloads69]

I was just looking at my insurance plan and am not sure if it excludes it or not, because I know most insurance companies won't cover pills like viagra/cialis, etc but will cover an implant.

My plan says under exclusions:

"Treatment of sexual dysfunctions and sexual inadequacies. This exclusion does not apply to the treatment of organically-based conditions."

I've got a hydrocele that causes discomfort and makes erections harder to achieve/maintain, and after I had a bilateral fasciotomy my dick and legs go numb when I sit at certain positions. If I tell this to my urologist, surely a case could be made for me, right?

I don't really know what's considered an organically-based condition.

It's with a Blue Shield Silver 1950 PPO in CA that I purchased through the marketplace.

I don't know why I can only find a list of exclusions with most companies until after I purchase the insurance. It's ridiculous.

[newbie443]

I was just looking at my insurance plan and am not sure if it excludes it or not, because I know most insurance companies won't cover pills like viagra/cialis, etc but will cover an implant.

My plan says under exclusions:

"Treatment of sexual dysfunctions and sexual inadequacies. This exclusion does not apply to the treatment of organically-based conditions."

I've got a hydrocele that causes discomfort and makes erections harder to achieve/maintain, and after I had a bilateral fasciotomy my dick and legs go numb when I sit at certain positions. If I tell this to my urologist, surely a case could be made for me, right?

I don't really know what's considered an organically-based condition.

It's with a Blue Shield Silver 1950 PPO in CA that I purchased through the marketplace.

I don't know why I can only find a list of exclusions with most companies until after I purchase the insurance. It's ridiculous.

I would give them a call and ask. What my BCBSKS Gold plan says in my contract is this :

3. Penile Prosthesis for Physiological Impotence
Benefits are provided for a penile prosthesis required for physiological (not psychological) impotence,
subject to advance approval by the Company only in the following situations: trauma, radical pelvic
surgery, diabetes, Peyronie's Disease, vascular or neurological diseases when individual situation
warrants coverage in the Company's opinion.
To request advance approval, a written report prepared by Your Practitioner must be submitted to the
Company. The Company has the right to request and obtain medical information it considers needed to
determine whether benefits should be approved or not.

That is in the E. Special Situations section of my Comprehensive Program. I buy my plan from BCBSKS but it is the same plan and price as the one on the Market Place (Obama Care).