Introduction and implant info

[Lost Sheep]

Would they cover a prosthetic foot?

Would they cover a prosthetic outer ear?

Would they cover dental implants?

Would they cover knee or hip replacement?

Would they cover a prosthetic testicle? (If yes to this one, they are DEFINITELY discriminating against sexual activity for - maybe moral? - reasons not germane to health care at all)

Would they cover any sort of vaginal reconstruction? (If yes, I think they are very likely discriminating against men being able to have sex.)

And, of course, would they cover a breast implant for a breast cancer survivor?

[drjeeps]

Well, I am talking to the nice folks at Boston Medical, and will reach back out to the Dr. for the specific codes they used. However, I don't hold much hope for that.

I do have a contact in HR that is looking at some things for me. They are currently investigating internally with our partners and hope to give me some news next week.

I did send my plan info to Boston for them to look at.

[drjeeps]

So, here's the official HR response:

We appreciate your patience while we investigated your inquiry.
We performed a thorough review of both the plan document and the HDHP summary plan description and confirmed that the requested procedure is specifically listed as an exclusion by the plan.
We are obligated to administer the plan as written and therefore are not able to grant an exception. Please refer to the claims and appeals section within the SPD.
Thank you,

My response:

Thank you for the response. After reviewing this, I am formally asking for the following:

1. A written explanation from REDACTED that explains the reasoning of how providing a Phalloplasty for a non-biological male diagnosed with Sexual Dysphoria - which, according to the Mayo Clinic, includes this procedure - does not constitute Gender or Sexual Discrimination against me as a biological male.

Please note that EEOC Compliance Manual, Chapter 3: Employee Benefits - states:

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.

2. As per page #58 of the SPD – Mediation as an alternative dispute resolution to help resolve this issue.

In the event that the two requested items above are unable to be provided to me no later than 09/13/2019, please respond back to this email so I can determine my next steps in a timely manner.

According to our SPD"

Legal Action
If your plan is governed by ERISA, you have the right to bring a civil action under section 502(a) of ERISA if you are not satisfied with the outcome of the Appeals Procedure. In most instances, you may not initiate a legal action against Cigna until you have completed the Level-One and Level-Two appeal processes.

Our plan is governed by ERISA and I've done both appeals.

I'm not going to lie. This is really upsetting. I am now having to debate a potential civil suit vs. just paying $20k out of pocket. In my mind, it is the principle of the issue. Why am I paying for insurance, especially one that will fix it for a non-biological male?

Anyone know a really good medical lawyer?

[drjeeps]

The circle-jerk continues. Cigna denies, my company tells me to go thru Cigna. Cigna denies, HR says they can't do anything...

This just hit my inbox from HR today:

This letter responds to your request for a written response related to the denial of your claim for certain medical services. XYZ Inc. is the sponsor of the medical plan, and in accordance with the requirements under the Employee Retirement Income Security Act (ERISA), is required to administer the plan according to its terms. XYZ Inc. has also delegated the claims and appeals functions to our third-party administrator CIGNA. We refer you to CIGNA for the written explanation, as they are responsible for interpreting the plan terms and in your case, they have determined that the requested procedure is listed as an excludable service.

With respect to your request for mediation, our plan terms do not require mediation. We have not included this option at this time.

As plan sponsor, we evaluate our plan design on a regular basis, and will be doing so for possible future enhancements. At this time, we make no guarantee that your requested service will be removed from the excluded list and added as a permissible benefit.

Screw it. I just filed with EEOC to lodge a formal complaint of sexual discrimination. Now the fun begins as the earliest I can get an interview to talk to them in 12/20/2019. Seriously. So I guess no working penis in 2019 for me unless I shuck out the $20k.

According to our lovely insurance package, I can press a civil suit after two appeals being denied. Boston Scientific has provided me with a group to speak with and I'll do that tomorrow.

I'm really flipping sick of spending each night reading medical law, medical information, and insurance benefit package crap.

At least I have a nice tumbler of Fireside Whiskey here. An adult beverage is the only thing keeping me sane tonight.

[drjeeps]

Boston Medical referred me to Morgan & Morgan - I just sent an inquiry and will let you know what they say from the legal standpoint.

[MK1965]

drjeeps,
You are brave man, determined to win and you’re gonna win.
MK

[drjeeps]

Long time since my original posting.

I've changed jobs 2 times now since originally posting this. Last company didn't discriminate, just didn't cover it, and was so old school that they didn't want to either. The job wasn't worth staying with and I've gotten a fantastic new job that I love. The good news is that my current company covers implants with zero fuss.

So, I'm sitting here chilling the boys on Day 2 after my surgery. AMS LGX 18cm +2RTE. Going fairly well so far. Obvious swelling, and bruising, but the pain is not horrible, and I've learned how to urinate with a semi LOL. Due to the PD, the doc did some modelling and looks like he did it pretty good. I'm about 50% inflated is my guess.

So, just resting, keeping everything supported, and waiting. I've gotten good at that after 6 years!

[Old Guy]

Long time since my original posting.

So, just resting, keeping everything supported, and waiting. I've gotten good at that after 6 years!

Congrats! Glad you finally got coverage. Waiting that long stinks.
Lurking around FT probably gave you tons of info. I wasn't so lucky and only found FT 5 months after my implant.

[SWorks17]

Congratulations Drjeeps!

I’m so glad for you and your wife!

Heal up and start using your Bionic toy!

Reach out with any questions to your FrankTalk brothers, but with all the years that you’ve been on FrankTalk you have your Doctorate Degree by now!

[drjeeps]

Day 18 Update:

No real pain since surgery, mostly just some discomfort as the new neighbor tends to piss off the left tenant mostly. I've been able to move the pump around just enough to make it reasonable. I did have an issue around Day 8 where the infighting was bad enough I took a day to lay flat out again and ice all day. Better after that.

Swelling is 95% gone, except on the left - testicle is swollen a bit and the skin is tight on that side. Bruising was absolutely EPIC, but is 95% gone.

Underwear, compression shorts, and jocks all SUCK. If one works sitting, it doesn't walking and vice-versa. Going commando has actually been the best when sitting.

Doc cleared me to start cycling last week. Due to the swelling at the time, he did not deflate me and instructed me to try it when things were easier to find.

Well, they aren't LOL. Bulb is easy to find, brick is mostly easy, but the button isn't. He was happy with the positioning, but I believe the button is pointing left right into the back of the testicle. I grit my teeth a few times and actually thought I had it, but no matter the force of my grip, I could not get it to deflate. As the swelling isn't totally gone, I cannot see the pump clearly like in videos where they simply pull the scrotum skin taught over the pump. Sure, but bulb is visible, but the block isn't, and I think it is turned like I mentioned.

He contacted me over the weekend to see how that is going and instructed me to come to his office on Tuesday if I'm still unable to find it.

A few notes: I can't really move the pump around much, so don't know how much more repositioning I can do with it. Also, I have never been big, but was about 6-ish" on a good day prior to getting cancer 6 years ago. Right now, at the level I'm pumped up, I'm just under 5". I don't think I'm 100% and the doc said I'll get about .5cm back in his estimation from when they did the saline fill injection at the start of the surgery. That is a disappointment after years of VED use to not lose anything. In the VED, I was 6-6.25 so I'd hoped to get close. I guess the next hope is the VED after I start cycling as others have stated.

However, on the positive (and no, I was not cleared to do this), I can say that it has been test driven in manual mode to satisfaction, and I was able to have very careful intercourse for the first time in 6 years with my wife with both of us being able to release. That alone was worth the price of admission and a huge blessing.

So, off to find the "hidden" button and get to exercising this thing.