Tuesday, September 4, 2012

Insurance Specific Transgender Exclusion for Surgery

I recently pursued the avenue of using my employer insurance (Aetna) for gender reassignment surgery. I met all the prerequisites, have my letters and this is the last step in my transition. I have been on hormones for six years, and they are covered through Express Scripts. Name change is done. As for the surgery itself, everything started off great.
The surgeon graciously offered me a discount and initially that would come out of pocket anyway.We filed and initially it came back excellent, all I would pay is the surgery fee itself, transportation, and staying there for one or two weeks to be checked on and part of that would be reimbursed. It was expected to cover the hospital stay as well. Of course later I received a notice saying it was not covered, and that my employer in fact has a specific exclusion in our policy. This struck me slightly odd, as I noticed my employer does have gender identity/expression listed in the harassment and opportunity posters that are posted. This seems to be the next logical step.
Below is Aetnas requirements for surgery. The foundation is there, I just do not understand in this day in age why it is not covered. The arguement seems to be that it is "cosmetic", but when I spend everyday of my waking life miserable because so much time has passed already and I do not forsee having the funds for another five years on my own, because life just keeps happening. WIthout surgery you have to take extra pills, putting you at more risk, you can't wear many things, (I have not been swimming in fifteen years). Not to mention the huge safety risk. It wears on you. Even something like checking an id at work can hamper your day. I would think the reduced medication, therapy, and doctor visit costs over the next 2-5 years would make up a lot of the difference. Could even require employment for a year.
Even it was a meet halfway deal, like I pay the surgery and they pay the hospital/anesthesia less deductible. Trying to be realistic too. Even though I seem to be the only transsexual in the company, out of 200,000+, I would guess there are at least five to ten others, so I cannot see costs expanding that much for these surgeries. I would not mind either if I had to have a higher tier/expensive plan. We have two now as it is, a third with more coverage would not be a big deal. 

Below is Aetnas policy and requirements, which I fit perfectly, as I am sure many others do. 

Clinical Policy Bulletin:
Gender Reassignment Surgery
Number: 0615


Policy

Note: Most Aetna plans exclude coverage of sex change surgery (gender reassignment surgery, transgender surgery) or any treatment of gender identity disorders.  Please check benefit plan descriptions. 
Aetna considers sex reassignment surgery medically necessary when all of the following criteria are met:
  1. Member is at least 18 years old; and
  2. Member has met criteria for the diagnosis of "true" transsexualism, including:
    • A sense of estrangement from one's own body, so that any evidence of one's own biological sex is regarded as repugnant; and
    • A stable transsexual orientation evidenced by a desire to be rid of one's genitals and to live in society as a member of the other sex for at least 2 years, that is, not limited to periods of stress; and
    • Absence of physical inter-sex of genetic abnormality; and
    • Does not gain sexual arousal from cross-dressing; and
    • Life-long sense of belonging to the opposite sex and of having been born into the wrong sex, often since childhood; and
    • Not due to another biological, chromosomal or associated psychiatric disorder, such as schizophrenia; and
    • Wishes to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
  3. Member has completed a recognized program of transgender identity treatment as evidenced by all of the following:
    • A qualified mental health professional* who has been acquainted with the member for at least 18 months recommends sex reassignment surgery documented in the form of a written comprehensive evaluation; and
    • For genital surgical sex reassignment, a second concurring recommendation by another qualified mental health professional * must be documented in the form of a written expert opinion**; and
    • For genital surgical sex reassignment, member has undergone a urological examination for the purpose of identifying and perhaps treating abnormalities of the genitourinary tract, since genital surgical sex reassignment includes the invasion of, and the alteraton of, the genitourinary tract (urological examination is not required for persons not undergoing genital reassignment); and
    • Member has demonstrated an understanding of the proposed male-to-female or female-to-male sex reassignment surgery with its attendant costs, required lengths of hospitalization, likely complications, and post surgical rehabilitation requirements of the planned surgery; and
    • Psychotherapy is not an absolute requirement for surgery unless the mental health professional's initial assessment leads to a recommendation for psychotherapy that specifies the goals of treatment, estimates its frequency and duration throughout the real life experience (usually a minimum of 3 months); and
    • For genital surgical sex reassignment, the member has successfully lived and worked within the desired gender role full-time for at least 12 months (so-called real-life experience), without periods of returning to the original gender; and
    • For genital surgical sex reassignment, member has received at least 12 months of continuous hormonal sex reassignment therapy recommended by a mental health professional and carried out by an endocrinologist (which can be simultaneous with the real-life experience), unless medically contraindicated.
* At least one of the two clinical behavioral scientists making the favorable recommendation for surgical (genital) sex reassignment must possess a doctoral degree (e.g., Ph.D., Ed.D., D.Sc., D.S.W., Psy.D., or M.D.). Note: Evaluation of candidacy for sex reassignment surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. Please check benefit plan descriptions.
** Either two separate letters or one letter with two signatures is acceptable.
Medically necessary core surgical procedures for female to male persons include: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty and placement of testicular prostheses, and erectile prostheses.
Medically necessary core surgical procedures for male to female persons include: penectomy, orchidectomy, vaginoplasty, clitoroplasty, and labiaplasty.
Note: Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction thyroid chondroplasty, hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing, which have been used in feminization, are considered cosmetic. Similarly, chin implants, nose implants, and lip reduction, which have been used to assist masculinization, are considered cosmetic.
Note on gender specific services for transgender persons:
Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy. Examples include:
  1. Breast cancer screening may be medically necessary for female to male transgender persons who have not undergone a mastectomy;
  2. Prostate cancer screening may be medically necessary for male to female transgender individuals who have retained their prostate.

Background
Transsexualism is "a gender identity disorder in which the person manifests, with constant and persistent conviction, the desire to live as a member of the opposite sex and progressively take steps to live in the opposite sex role full-time."  People who wish to change their sex may be referred to as "Transsexuals" or as people suffering from "Gender Dysphoria" (meaning unhappiness with one's gender).
Transsexuals usually present to the medical profession with a diagnosis of transsexualism, a sophisticated understanding of their condition, and a desired course of treatment, that is, hormone therapy and sex-reassignment surgery.  The therapeutic approach to gender identity disorder consists of three parts: a real life experience in the desired role, hormones of the desired gender, and surgery to change the genitalia and other sex characteristics (Day, 2002). The most typical order, if all three elements are undertaken, is hormones followed by real life experience and, finally, surgery.
For male to female transsexuals selected for surgery, procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty), breast augmentation and cosmetic surgery (facial reshaping, rhinoplasty, abdominoplasty, laryngeal shaving, vocal cord shortening, hair transplants) (Day, 2002). For female to male transsexuals, surgical procedures may include genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, chest wall contouring and cosmetic surgery (Day, 1992).
Due to the far-reaching and irreversible results of hormonal and/or surgical transformational measures, a careful diagnosis and differential diagnosis is absolutely vital to the patient's best interest.  In and of themselves, a patient's self-diagnosis and the intensity of his desire for sex reassignment cannot be viewed as reliable indicators of transsexuality.  A vital part of the long-term diagnostic therapy is the so-called real-life experience, in which the patient lives as a member of the desired sex continually and in all social spheres in order to accumulate necessary experience.  Experience in specialist Gender Identity Units has shown that only about 15% of male transsexuals and 90% of female transsexuals are considered suitable for surgery or still desire it after specialist psychiatric care and a prolonged period of observation used to identify the relatively rare "true" transsexual from the more common "secondary" transsexual.
Hormone therapy and sex-reassignment surgery are superficial changes in comparison to the major psychological adjustments necessary in changing sex.  Treatment should concentrate on the psychological adjustment, with hormone therapy and sex-reassignment surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment.  Psychiatric care may need to be continued for many years after sex-reassignment surgery.  The technical success of sex-reassignment surgery is greater for male-to-female transsexuals than female-to-male transsexuals, and continues to improve as new techniques are developed.  The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the transsexual, and the support from family, friends, employers and the medical profession.

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