Medically Necessary Letters
Your insurance will have very specific requirements to meet their criteria when transitioning. It is important to know this because each insurance is independent. There are hundreds if not thousands of different combinations of insurances that sometimes have the same umbrella name but are uniquely different. For example, some insurance plans require that you provide two letters and be transitioning for a minimum of three years.
A medical provider can write a letter that a surgery or prosthetic is medically necessary. Whereas a mental health provider can write a letter on how a surgery or prosthetic will improve your mental health and help in the treatment of your gender dysphoria. It is left to the letter writer to determine how many visits are needed before they are comfortable writing a letter.
A review of your insurance member handbook will be an important and critical tool for gender affirming care. It will determine your deductible, what is and is not covered, and what they claim to be cosmetic.
Provider and Mental Health letters typically Include:
A statement that, in the doctors or mental health professional opinion, the treatment is medically necessary and the appropriate step during care for the patient’s gender dysphoria. Some plans also require clinical codes to be used.
A brief description of the patient’s medical history. This may include how long the patient has been in their care or the medical records of how long the patient his been transitioning. How long the patient has been on hormone replacement therapy or living as the gender they identify with.
An explanation of why this procedure is medically necessary for this patient. It is customary for the letter to follow the World Professional Association for Transgender Health’s most recent standard and citation of the volume and page.
Relevant studies that demonstrate the effectiveness of the treatments that the patient is seeking. The letter can also refer to clinical guidelines.
The health care providers training in transgender-related care should be documented in the letter.
If the coverage is denied, an appeal will be necessary with the reason for the denial and why it is medically necessary. There are often sensitive time restraints that must be followed. The appeal should be addressed in an urgent manner to protect your time restraints. Citations of coverage by your plan, the California Department of Managed Healthcare and the WPATH are important to cite.