Thursday, July 18, 2024

Does Medicare Cover Top Surgery

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Does Medicare Cover Top Surgery

Does Medicare Cover Cataract Surgery?

This might sound like a totally irrelevant and dumb question. After all, if you have made it through the majority of your life with the physical attributes that you have, now being 65 years of age or older, why bother to pursue top surgery? You probably have adapted and, with your elder status, there are likely increased risks for surgery at this point in your life.

Do you really want to take these chances?

Well, this is not as straightforward as most people think.


Most people assume that you have to be 65 years of age or older in order to be on Medicare. This is largely true. However, Medicare is also available to those who are younger than 65 and who have specific disabilities. So, yes, there are many people who are on Medicare and are under 65 years of age.

And yes, there are transgender individuals who are 65 and older who DO WANT gender affirming surgery.

Around 75% of all transgender Medicare beneficiaries are under 65 years of age . This is the subset that would be the more likely to pursue top surgery. However, and somewhat ironically, it was the persistence and legal challenges of a 75 year old transgender individual that ultimately led to Medicare no longer being able to refuse coverage for any gender confirming surgery.

So, if you are a transgender individual truly wanting to undergo top surgery and just happen to have Medicare insurance, you do want to know whether or not Medicare will cover top surgery.

Cpt Codes Not Covered For Indications Listed In The Cpb :

11950 – 11954 Subcutaneous injection of filling material 15200 Full thickness graft, free, including direct closure of donor site, trunk 20 sq cm or less 15775 Punch graft for hair transplant 1 to 15 punch grafts 15776 Punch graft for hair transplant more than 15 punch grafts 15780 – 15787 Excision, excessive skin and subcutaneous tissue abdomen, infraumbilical panniculectomy 15876 – 15879 Electrolysis epilation, each 30 minutes 19301 Mastectomy, partial 19303 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 20999 Unlisted procedure, musculoskeletal system, general 21087 Genioplasty 21125 – 21127 21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy without bone graft 21194 with bone graft 21195 Reconstruction of mandibular rami and/or body, sagittal split without internal rigid fixation 21196 Osteoplasty, facial bones augmentation 21210 Graft, bone nasal, maxillary or malar areas 21270 Unlisted procedure, larynx 31899 Unlisted procedure, trachea, bronchi 40799 Unlisted procedure, lips 67900 Repair of brow ptosis 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder individual 92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder group, two or more individuals

What Is Hormone Therapy

Hormone therapy is when you take medication to help you look and feel more like the gender you really are. It’s usually the first step of your journey towards transitioning and will make you look more like the other sex. For example, individuals born as female will take androgens which will make them look more masculine. Those born male will take oestrogen and anti-androgens which will make them look more feminine.

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Reasons For Wanting To Have Gender Affirmation/confirmation Surgery

Whilst Transgender people do not need medical intervention to have valid identities many choose to transition. This can involve Social and/or Medical transitioning.

  • Social transitioning: refers to going by different pronouns, changing ones style, adopting a new name, etc., to affirm ones gender
  • Medical Transitioning involves taking hormones and/or surgically removing or modifying genitals and reproductive organs. This is what we refer to when talking about Gender Affirmation or confirmation surgery

Gender Confirmation surgery is one of the most complex operations in the field of plastic surgery. It not only changes the complete external physical appearance of the individual but their overall identity as well.

What Questions Should I Ask Before Surgery

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Its important to talk about the pros and cons of surgery in detail with your doctor. Its a good idea to ask to see pictures of how other people look after surgery.

  • What different surgical techniques are there?
  • What are the pros and cons of each technique for me?
  • What results can I expect?
  • What are the possible risks and complications?

For help in having the discussion, visit healthdirects Question Builder.

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Medicare Advantage Plans And Gender Reassignment

By law, Advantage plans must offer the same benefits as Medicare. Gender reassignment surgery should be covered no matter what kind of Medicare plan you have. But, some Medicare Advantage plans have extra guidelines related to coverage for transition surgery.

The National Center for Transgender Equality recommends that you get pre-authorization from your Advantage plan before you get healthcare related to your transition.

Also, unlike Medicare, Advantage plans rely on networks. Youll pay much less for healthcare if you use in-network providers.

Some plans may not cover out-of-network care. Also, this can pose a problem if you cant find a doctor in your plans network who can perform gender reassignment surgery.

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Contact your plan if youre struggling to find in-network care. Advantage plans set their own deductibles and co-pays, so your costs with an Advantage plan may be different than Medicare.

Repairing A Malformed Body Part To Improve Function

Birth defects, aging, and disease can all impair proper functioning of some body parts. Congenital or developmental abnormalities can also affect the way certain body parts are formed. Diseases are yet another possible cause of abnormal body structure and lack of function. In some cases, plastic surgery can be used to help improve the function of these affected body parts.

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Jaw Surgery Coverage Limits

Through your Original Medicare Part A coverage you are responsible for the Part A deductible which is $1408.00 per benefit period in 2020. There is no coinsurance for the initial 60 days of a hospital stay per benefit period. If you stay longer than 60 days, you must pay coinsurance according to Medicares rates.

Your Part A coverage for orthognathic surgery extends to care in a skilled nursing home if you need to have special monitoring during your recovery. Skilled nursing care is covered when it follows an inpatient hospital stay of three days. This coverage doesnt include custodial care if that is the only care you need.

If you have orthognathic surgery as an outpatient, Original Medicare Part B covers a percentage of the surgery. You are responsible for your annual deductible $198.00 in 2020 and your monthly Part B premium. Medicare pays 80 percent of the final approved cost of the surgery and you pay the remaining 20 percent. If you have a Medigap plan, you may have coverage for the copayment as well as the Part B deductible. This depends on which Medigap plan you have.

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Appealing Your Medical Necessity Or Out

Does Medicare Cover Dental

Denial notice. If your treatment is denied, your insurer must notify you in writing, and by telephone for urgent cases, unless you request electronic notification. If you dont get a notice, file a complaint with DFS.

Timeframes. You have 180 days to appeal with your insurer.

Clinical Review Criteria. You have a right to get a copy of the clinical review criteria your insurer used to make its decision from your insurer at any time.

Out-of-Network Provider Appeal . Your doctor must send a written statement to your insurer that the in-network providers recommended by your insurer do not have the training and experience to meet your health care needs and recommend an out-of-network provider with the training and experience to meet your health care needs who is able to provide the service.

Out-of-Network Provider Appeal . Your doctor must send a written statement to your insurer that the out-of-network service is materially different from the health service the insurer approved and provide two documents of medical evidence that: the out-of-network service is likely to be more clinically beneficial than the in-network service your insurer recommended and the risk would not be increased over the in-network health service.

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How To Get Extra Medicare Coverage For Your Surgery

If youd like 20% extra coverage in the form of a Medigap plan, give us a call at the number above. We have agents in every state, waiting to help. Also, we can help you compare plan options in your area. Were committed to finding the best plan for your needs and budget.

Another option is to fill out our online rates form to see your rates now.

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Is Gender Confirmation Surgery Covered By Medicare

Yes, but only partly. Medicare can cover some of the individual treatments associated with gender confirmation surgery including surgeries, medications, tests and consultations. Approved treatments are listed on the Medicare Benefits Schedule , but you will still need your doctor’s referral to get covered. Here are some examples of the treatments that Medicare can pay towards:

  • Vaginal reconstruction
  • Exploration of spermatic cord

Medicare can also cover your GP visits, blood tests, psychological counselling and a few prescriptions again, with the right referrals from your doctor.

Unfortunately though, you’ll still face significant out-of-pocket expenses. This is because specialist care for trans people and those with gender dysphoria is in extremely short supply in Australia. Most surgeries are performed privately and private doctors are free to charge more than what a public facility would . Because there is such a short supply, fees are likely to be high. Medicare will pay 75-85% of the MBS fee but you could still be faced with thousands of dollars left to pay.

What Medicare won’t cover

There are a few treatments that Medicare won’t pay for at all. Along with the expenses mentioned above, you will also need to come up with the full amount for the following, unless you have private health insurance:

  • Your accommodation and theatre fees
  • Cosmetic surgery that is considered not medically necessary
  • Some medications for hormone replacement therapy

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How Much Does Medicare Pay For Heart Surgery

The average cost of heart bypass surgery is over $100,000, but Medicare will cover a large portion. Now, even if Medicare covers 80% and there are no excess charges, you could still be responsible for a large bill.

Inpatient procedures will cost you the Part A deductible and 20% coinsurance unless you have additional coverage. Outpatient procedures will cost the Part B deductible and 20% coinsurance when you only have Medicare.

You may pay over $20,000 for your heart bypass if you only have Medicare. Signing up for extra insurance can save you quite a bit of money.

Format For Referral Letters From Qualified Health Professional

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  • Clients general identifying characteristics and
  • Results of the clients psychosocial assessment, including any diagnoses and
  • The duration of the mental health professionals relationship with the client, including the type of evaluation and therapy or counseling to date and
  • An explanation that the WPATH criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patients request for surgery and
  • A statement about the fact that informed consent has been obtained from the patient and
  • A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.
  • Note: There is no minimum duration of relationship required with mental health professional. It is the professionals judgment as to the appropriate length of time before a referral letter can appropriately be written. A common period of time is three months, but there is significant variation in both directions. When two letters are required, the second referral is intended to be an evaluative consultation, not a representation of an ongoing long-term therapeutic relationship, and can be written by a medical practitioner of sufficient experience with gender dysphoria.

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    What Is Gender Reassignment Surgery

    According to the American Society of Plastic Surgeons, that goal of gender reassignment surgery is âto give transgender individuals the physical appearance and functional abilities of the gender they know themselves to be.â

    For male to female gender reassignment surgeries there are three categories:

    • Facial feminization surgery to transform masculine features of the face into a more feminine appearance
    • Transfeminine top surgery to enhance the size and shape of the breasts
    • Transfeminine bottom surgery to transform male genitalia and reconstruct it into that of a female.

    For female to male gender reassignment surgeries there also three categories:

    • Facial masculinization surgery to transform feminine features into a more masculine appearance
    • Transmasculine top surgery to remove breast tissue and create a more masculine appearance of the chest
    • Transmasculine bottom surgery to transform female genitalia and reconstruct it into that of a male

    Specific gender reassignment surgeries, according to could include:

    How Does Medicare Decide If Your Gender Affirmation Is Covered

    It can sometimes be difficult to determine whether Medicare will cover a service or not. Coverage decisions for Medicare plans are generally governed by the following factors:

    • Federal laws. These laws determine what benefits insurance companies offer and whos licensed to provide these services in your state.
    • National coverage laws. These decisions are made by Medicare directly and determine what is and isnt covered.
    • Local coverage laws. These decisions are made by companies and determine whether something is medically necessary or not under Medicare.

    The best way to determine if your gender affirmation procedure is covered by your Medicare plan is to speak with your doctor directly.

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    Cpt Codes Covered If Selection Criteria Are Met:

    13131 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet 1.1 cm to 2.5 cm 13132 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet 2.6 cm to 7.5 cm 13133 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet each additional 5 cm or less 13160 Secondary closure of surgical wound or dehiscence, extensive or complicated 14021 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs defect 10.1 sq cm to 30.0 sq cm 14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet defect 10 sq cm or less 14041 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet defect 10.1 sq cm to 30.0 sq cm 14301 Adjacent tissue transfer or rearrangement, any area defect 30.1 sq cm to 60.0 sq cm 14302 Adjacent tissue transfer or rearrangement, any area each additional 30.0 sq cm, or part thereof 15002 -15003 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar , or incisional release of scar contracture, trunk, arms, legs first 100 sq cm or 1% of body area of infants and children. + each additional 15100 – 15101 Split-thickness autograft, trunk, arms, legs first 100 sq cm or less, or 1% of body area of infants and children + each additional 1% 15574 15750 19318 Nipple/areola reconstruction

    Recent Events Affecting Transgender Surgeries

    â? Does Medicare Cover Cataract Surgery? Should You Wait?

    Fast-moving currents of both positive and negative change are affecting individuals access to gender reassignment treatments. To a growing extent, health insurance companies and large employers are covering gender-altering surgeries. A Willis Towers Watson industry survey found that an increasing number of employers are taking action to add transgender medical benefits. In December 2020, a federal prisoner in Wisconsin won her lawsuit demanding sexual reassignment surgery. And in May 2021, the Utah Supreme Court affirmed the right of transgender people to change their sex designation on their birth certificate.

    On the other hand, based on reporting by The New York Times, hundreds of bills restricting the rights of transgender people have been introduced across the U.S. Treating gender dysphoria in younger people is particularly controversial.

    For example, in May 2021, Karolinska hospital in Stockholm, the first in Sweden to offer gender identity assessments for children, stopped giving hormone treatment. This happened after the hospital found the treatments were causing serious, sometimes irreversible, side effects such as cardiovascular disease, osteoporosis, infertility, cancer, and thrombosis.

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    When Does Medicare Cover Orthognathic Surgery

    How your Medicare insurance pays for your jaw surgery depends on where the surgery takes place.

    If you are admitted into a Medicare-affiliated hospital as an inpatient, Original Medicare Part A covers its share of the costs of surgery and the following:

    • A semi-private room and meals
    • General nursing care
    • Drugs that you get for inpatient treatment
    • Some other hospital services and supplies but no personal supplies

    While you are an inpatient, all care from your physicians and surgeons is covered by your Original Medicare Part B benefits, not Part A benefits.

    TIP: are you ready to test your knowledge? Take our Medicare quiz and see how you score.

    Medicare Advantage Coverage For Surgery

    Medicare Advantage plans are administered by private companies that contract with the federal government. Plans must include the same basic care as Original Medicare but often bundle other benefits such as vision and dental into a single plan.

    Medicare Advantage plans may require you to use hospitals and doctors within the plans network for your surgery. Prior authorization is usually required.Medicare Advantage plans may also have different deductibles, coinsurance and copayments for surgery than Original Medicare.

    For example, the AARP Medicare Advantage Choice plan features a $295 per day coinsurance payment for inpatient hospital care . This is in addition to the standard Medicare Part A deductible of $1,556 in 2022.

    After day six, there are no coinsurance payments with this plan.

    A different Medicare Advantage plan UnitedHealthcare Dual Complete® RP features $0 copayments for each Medicare-covered hospital stay for unlimited days, as long as the hospital is within the plans network.

    In contrast, Original Medicares inpatient hospital policy features a $0 coinsurance payment for the first 60 days of inpatient care after you meet the Part A deductible.

    Contact your specific Medicare Advantage plans customer service department or consult your annual evidence of coverage manual for details about inpatient and outpatient surgery coverage.

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