Is Blue Cross Trying To Deny SRS to a California Resident? Devil in the details

The following comment were posted on on reddit  by a reader regarding this picture.  I am not a expert on this and offer this comment for discussion..

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I believe that letter is intentionally trying to mislead you, by understating your rights under CA DMHC Letter 12-K[1].


I'm beginning the process of asserting my rights to medically necessary transition care. I'm posting my research and strategy, in the hopes that it may inspire others to seek the full range of care their insurers are obligated to provide.

First, let's hit the low-hanging fruit: SRS coverage. Blue Shield implies this will be excluded:

"... coverage for medical services related to gender transition will not be denied if coverage is available for those services when not related to gender transition."

Letter 12-K explicitly states SRS cannot be excluded:

Examples of EOC language that is inconsistent with the Knox-Keene Act (...) are those that seek to exclude coverage of "(1) transsexual surgery" and/or (2) "transgender or gender dysphoria conditions".

transgenderlawcenter.org's FAQ[2] on Letter 12-K agrees with this analysis:

What will be covered? Who decides?

The DMHC Director’s Letter states that medically necessary transition-related surgery and other care must be covered by health care insurance sold in California. However, if a claim is denied, what constitutes medically necessary care for a particular individual will be determined through the independent medical review process.

Now that we've established the right to SRS, let's explore what other transition-related care they can no longer deny us. To do this, let's first look at another section of Letter 12-K:

Required Action by Health Plans

1) Ensure that individuals are not denied access to medically necessary care because of the individual's gender, gender identity, or gender expression;

(...)

3) Revise all current health plan documents to remove benefit and coverage exclusions and limitations related to gender transition services;

If you add these two together, you get a very strong case that it's illegal to deny medically necessary transition services. I wish this part had zero ambiguity, but it becomes clear as day as each of us defeats insurance companies that seek to deny us this care.

Next, we consult WPATH's Medical Necessity Statement[3], for a broad list of medically necessary services:

"Medically necessary sex reassignment procedures also include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient (including breast prostheses if necessary), genital reconstruction (by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, penile and testicular prostheses, as necessary), facial hair removal, and certain facial plastic reconstruction as appropriate to the patient.

"Non-genital surgical procedures are routinely performed... notably, subcutaneous mastectomy in female-to-male transsexuals, and facial feminization surgery, and/or breast augmentation in male-to-female transsexuals. These surgical interventions are often of greater practical significance in the patient's daily life than reconstruction of the genitals."


"Furthermore, not every patient will have a medical need for identical procedures; clinically appropriate treatments must be determined on an individualized basis with the patient's physician."


So, the singular expert board lists a ton of services as medically necessary, and gives our physicians room to expand upon what's medically necessary for each individual, with different needs. We've already established Letter 12-K all but says medically necessary transition-related care must not be denied. Therefor, it follows that this class of care must be covered.


So, what if your insurance company pulls a Blue Shield, and still seeks to deny you care? Transgender Law Center has the answer:

What if I am denied coverage for my transition-related care?

If a patient is denied coverage, they should contact the DMHC Department of Managed Health Care’s Help Center at 1-888-466-2219 / www.HealthHelp.ca.gov

If you are covered by a PPO it is likely regulated by the Department of Insurance. Their helpline can be reached at 800-927-HELP / www.insurance.ca.gov/contact-us/

Patients should also contact Transgender Law Center’s helpline for assistance with the IMR process at 415.865.0176 x306 / www.transgenderlawcenter.org

The commenter continued explaining her plan:
I'm using all this as a basis to fight for my right to facial hair removal, which is in WPATH's medically necessary care list. More low hanging fruit. Kaiser Permanente claims this still isn't covered. They lie. I'm going to obtain advice from my Dr on how best to get this service, get it done, and then litigate reimbursement as outlined by the Transgender Law Center. Upon success, I'll post here, detailing how others can attempt to replicate my success, for this and all other medically necessary transition care.

No power in the verse can stop me. All the same, please wish me luck.

[1] Letter 12-K: http://transgenderlawcenter.org/wp-content/uploads/2013/04/DMHC-Director-Letter-re-Gender-NonDiscrimination-Requirements.pdf

[2] Transgender Law Center's Letter 12-K FAQ: http://transgenderlawcenter.org/archives/4273

[3] WPATH's Medical Necessity Statement: http://www.wpath.org/medical_necessity_statement.cfm