What Constitutes Medical Necessity for “Tops” Surgery
Understand Your Insurance Benefits!
Insurance coverage and benefits vary between providers and may change again in the near future. In the meantime, it is important to read and understand your plan’s information booklet. Insurance policies can be confusing, and therefore it is recommended that you call and talk to a representative at your insurance company or ask your surgeon’s office to check benefits and requirements for you.
There was a ruling by the Department of Health and Human Services in May 2016 that went into effect in July 2016, which prohibits exclusions in health plans that receive federal funding. Your insurance company may be in violation of federal regulations if your plan has exclusions for transition related treatments.
If your policy does cover “Tops” surgery, you will want to find a surgeon that accepts your insurance and submit a request for pre-authorization. If your request is denied, be sure to file an appeal, many patients get coverage through appeals.
If it is determined that “medical necessity” is required to approve surgery, there are certain things the insurance company may be looking for. For example, a written psychological evaluation from at least 1 health provider trained in treating gender dysphoria and can meet the following criteria:
• Persistent, well documented gender dysphoria
• Ability to make an informed decision and consent for treatment
• A minimum of 18 years old
• Any medical or mental health concerns must be controlled
Hormone therapy for Top surgery is not required unless you are trying to get medical insurance to cover the surgery. Many insurance companies require 1 year of Hormone Replacement Therapy (HRT).
Let Us Help You!!
If dealing with insurance companies has been a daunting experience for you, many doctor’s offices, such as Dr. Miguel Delgado, M.D. are glad to step in and help patients apply for per-authorization and even an appeal if that should become necessary.
With all the possible changes that could take place with medical insurance, if you have coverage now and are contemplating surgery, you might want to explore your options soon before coverage may be terminated.
Call today (415) 898-4161 for a confidential consultation with Dr. Delgado.
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