Introduction and implant info

The final frontier. Deciding when, if and how.

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Lost Sheep
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Re: Introduction and implant info

Postby Lost Sheep » Tue Aug 27, 2019 3:00 pm

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?
Lost Sheep
Born 1948 AMS LGX 18+3 implant Nov 6, 2017 by Dr Tavis Shaw. Spent 14 months researching in effort to optimize outcome. After 30 yrs of progressive unrecognized ED I will do this RIGHT; no second chance with one's first.
Anchorage AK, USA

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drjeeps
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Re: Introduction and implant info

Postby drjeeps » Thu Aug 29, 2019 6:33 pm

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.

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drjeeps
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Re: Introduction and implant info

Postby drjeeps » Fri Sep 06, 2019 1:52 am

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?

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drjeeps
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Re: Introduction and implant info

Postby drjeeps » Wed Sep 11, 2019 11:05 pm

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.

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drjeeps
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Re: Introduction and implant info

Postby drjeeps » Wed Sep 11, 2019 11:23 pm

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
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Joined: Thu May 24, 2018 5:32 pm

Re: Introduction and implant info

Postby MK1965 » Thu Sep 12, 2019 7:31 am

drjeeps,
You are brave man, determined to win and you’re gonna win.
MK
IPP 9/5/18; Coloplast TITAN OTR 18 cm 1cm RTE, Dr. Khera Baylor Houston,Prostate Ca at 51 y/o; RARP 11/2/16, ED Post RP, Cialis, Viagra, VED no usable erection, April 2017, TRIMIX painful, BIMIX tolerable but ineffective,lost 2+ inches of length after RP


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