I have a friend who has had most of her electrolysis reimbursed by her husband's company insurance policy. My insurance company says no way. Are there any insurance companies that cover electrolysis?

All Insurance companies must cover electrolysis when prescribed by a doctor. Where they differ is how much trouble they put the insured through before they pay up.

Some will only reimburse, others will pay the doctor, who pays the electrologist, and still others will cut a check directly to the electrologist.

Keep in mind that if you are being treated for a hormonal imbalance, electrolysis is necessary to completely reverse the effects of that imbalance. The drugs may restore the chemical composition of your system internally, but you need electrolysis to remove the outward expression of that period of imbalance outwardly. Some medications your doctor prescribes will also have unwanted hair growth as a side effect. Many birth control pills have this problem. Attending to this side effect should be a part of your treatment program up front. Of course, only you will ever bring this up, so make sure that you take your medical care proactively and get all that you have got coming to you.

my doctor says, they never pay for it since it is considered cosmetic... is she wrong? I am 16 and have ridiculous amount of facial hair, and most likely have a hormone imbalance. is there anyway I can get my insurance to pay for it?

quote:

---

Originally posted by James W. Walker VII, CPE:
All Insurance companies must cover electrolysis when prescribed by a doctor. Where they differ is how much trouble they put the insured through before the pay up.

Some will only reimburse, others will pay the doctor, who pays the electrologist, and still overs will cut a check directly to the electrologist.

Keep in mind that if you are being treated for a hormonal imbalance, electrolysis is necessary to completely reverse the effects of that imbalance. The drugs may restore the chemical composition of your system internally, but you need electrolysis to remove the outward expression of that peroid of imbalance outwardly. Some medications your doctor prescribes will also have unwanted hair growth as a side effect. Many birth control pills have this problem. Attending to this side effect should be a part of your treatment program up front. Of course, only you will ever bring this up, so make sure that you take your medical care proactively and get all that you have got coming to you.

---

You need a doctor who will co-operate with you, but you can get it done. If your hair problem is related to any medical condition, then treating it is a part of treating your over all condition.

When you have a doctor who does not take it seriously enough to prescribe treatment for you, then you won't get co-operation from the insurance company either. Just keep in mind that doctors get paid bonuses to help insurance companies keep their costs down.

I am also trying to get coverage for electrolysis. I have a letter from the doc, and currently I'm being given a little run around. But that's ok so far. It seems very logical that they'll have to pay to treat this medical condition like any other.
I could basically think of all the answers to any claims that the insurance company could make. But I'm having trouble with the following hypothetical question:
They could claim that excess hair, although a symptom of a diagnosable and treatable disorder, is in itself a cosmetic side effect. For instance, birth controll pills are sometimes prescribed for PCOS, and even though are otherwise a convenience, they still have a theraputic effect for the condition. The pills stabilize hormone levels, releive symptoms (restore periods, for example) and prevent complications. Whereas, excess hair is only a cosmetic symptom. It in itself is not dangerous, it cannot cause any complications -- the only bad part about it is the 'looks'. This is only a cosmetic problem, and cosmetics are not covered by any insurence plan.

Does anyone have any ideas about it?

So far I can only think of a psychological effect on the patient. Then it becomes a symptom of a medical condition, which causes other complications. But in this case one might have to prove the psychological effect or be diagnosed for it. Granted, no woman is very happy with this symptom, but still this complicates matters.

(Continued...)
Another example is if someone gets a bad sunburn. The burn is a medical condition and will be covered by insurance plans. If afterwards the patient develops skin cancer it is also a medical condition which compromises the patient's health, and he'll be covered.
But if the after effects of the burn are hyperpigmentation or wrinkles or any other deterioration of the 'looks' of the skin, no insurance will pay for plastic surgeries to reverse these conditions. These are purely cosmetic concerns that have no effect on the patient's health, even though they are a result of a diagnosable and treatable disorder (sunburn) which itself is covered.

I didn't get yet as far as facing this claim from the insurance company, but hypothetically, can anyone think of a way to persuasively counter such a claim?

Thanks.

I would doubt that you can ever get insurance to pay for it.

I had a medical disorder that makes my feet sweat excessively and tried getting the drionic machine that improves this condition. The drionic.com website even mentions that insurance pays for it since it is a condition that causes medical discomfort - they gave me all the insurance codes for the device. However, my insurance company (which is generally very good) rejected the claim outright.

Body hair doesn't even cause physical discomfort - embarrassment is not a physical issue.

Also remember that body hair, especially for men, was not considered an unattractive thing just a couple of decades back. In the 70s, people actually liked to show of their chest hair! I think that most docs are middle-aged and don't realize the trends in physical appearance these days. They also see countless patients unable to afford basic medical coverage, and will more than likely laugh at you when you ask them for hair removal insurance coverage.

I am talking about a medical condition which causes lots of hair to grow in all the wrong places on a female.

Anyway, you might deserve insurance coverage. I don't know about your condition and if what you want covered is the industry standard to treat your condition, but if it is, you will need to fight for the coverage. No one likes to give money away, but if they legally must, and YOU MAKE them, then they will. (At least it makes sence to me

Insurance companies are all about collecting premiums and never paying any claim they can avoid paying. Of the claims they do pay, they make sure to never pay anything any sooner than they have to. A good book to read on the insurance industry is "Invisible Bankers" by Andrew Tobias.

For something like this, you usually have to pursue them diligently, and be willing to file suit against them for either breach of promise, in large amounts, or in small claims court for small amounts.

Once your electrolysis costs reach $1,000.00 you are fully in line to take them to small claims court, and once you get the judgment, they will be more accommodating in future payments. They will tell you they lost your letter from the Doctor. It was never delivered. The worker who received your information no longer works there anymore and they don't know where she/he put your file. It is all a con!

I will post a letter here for your use in getting your treatment out of the insurance company some time soon. I don't have the time right now.

But in the matter of rationalizing why they don't have to pay, you need to understand that electrology is actually a part of the doctor's diagnostic treatment as well as returning you to your former state. How can the doctor evaluate the effectiveness of the medication you are using in turning back the continued growth of hair, if the previously grown hair is never removed?

In the case of your foot machine, they would/will pay if you file small claims case against them for reimbursement. They rely on people giving up if they put up a little resistence. They also know they can't win anything in an actual court (not binding arbitration, who do you think is paying the arbitor's salary?) because no judge and no jury has any sympathy for insurance companies. After all, finding a jury who has never had reason to have a grudge against one is just impossible.

Ok friends, this is going to be a book!

I asked my friend to post this, as it is his information, but since that has not happened since this post string started, I will add the information here myself.
--------------------------------------------------
First..... there is a legal principle involved here called “industry
precedent”. This means if one company in the industry pays....they all
have to pay. I have copies of letters from insurance companies that
rejected me and then paid me shortly afterward. They try to get out of
it by claiming we are not doctors or not licensed to do the procedure.
This usually works for them as the insured has no idea where to go from
here and many of the large states do not have licensing.

Insurance companies operate on the basis of two words.... DELAY and
DENY. They hope you will quit or die and that ends the case. They also
know no lawyer will take a case worth less than $50,000 as there is no
money in it for him, therefore, when they delay you it is a forgone
conclusion you will not sue them. If there are consumer protection
laws, as we have in Mass., that allow TREBLE DAMAGES PLUS ATTORNEY’s
FEES they hope you do not know about them but if you do know about
these laws they can always reverse their position and that will keep
you happy. A case in one of the Carolinas involved a girl with PCOS who
went to an Endocrinologist. She was told he could prescribe medication
but nothing was available to remove the hair except electrolysis and he
told her to find one and get treatment. She did what the doctor ordered
but the insurance company refused to pay. She sued and won. The
insurance company appealed and lost the appeal. The insurance company
took it to the state supreme court and argued the electrologist was not
a MEDICAL person. The court ruled, “ the doctor ordered it therefore it
was medical, no matter who did the work, as there is no licensing of
electrologists in that state”.

Insurance policies pay for DIAGNOSABLE AND TREATABLE DISORDERS. All
procedures and illnesses have a computer code for entry into the
computer. The code (called an ICD9 number) for the diagnosis of PCOS is
704.3 and the treatment is 17380. They will claim electrolysis is for
cosmetic purposes and they do not pay, however, the only cosmetic
procedures we do is eyebrows, underarms, and bikini lines. Everything
else is part of any one of a number of medical disorders. PCOS has
about 10 symptoms and if they are paying for the birth control pills
they have admitted the patient has a treatable disorder as there is no
medication for any cosmetic disorder.

Birth control pills are a CONVENIENCE for birth control. They are not
for a disease, however, in PCOS there is a hormone imbalance and the
hormones needed to restore the balance just happens to be in the birth
control pills or else the doctor can order the hormones separately and
it will cost more. Therefore the doctor has to write a letter stating
the medication is “medically necessary” and they will pay. This is a
routine procedure and they will pay to treat PCOS as it is common and
they know this. All doctors know about this and will write such a
letter. This is important as it establishes the patient has a treatable
condition for which medication has been prescribed.

Next.... AFTER you get a prescription reimbursed by the insurance Co.
you file for reimbursement of electrolysis treatments. They will still
maintain hair removal is cosmetic, however, too much hair in all the
wrong places is a medical problem and if needed visit a second doctor
to get a second opinion as they have to pay for this too. You will have
to appeal their decision and you have 3 appeals to go through. At the
third appeal you challenge them. NEVER SURRENDER THE POWER. MAKE THEM
KNOW YOU ARE NOT TAKING ANY NONSENSE and you will beat them in court
because of “industry precedent”. They have a contract to pay for all
diagnosable and treatable diseases and electrolysis is the “current
standard of medical treatment for this condition” (remember this
phrase...it is vital to your argument).

At the appeal ask the ombudsman who is usually running the show..... 1.
Are you a doctor?  2. Did you ever examine the patient ? 3. Would you
know what you were doing if you did examine the patient ? (If the
person running the show is a doctor..... ask if he/she is a specialist
in this disorder) 4. If they say it is “company policy” NOT TO PAY FOR
THIS, ask to see the company manual where this is stated. 5. Let them
know they are stating the Board Certified Doctors who made the
diagnosis are going to be notified the insurance company maintains the
doctors do not know what they are doing and they slandered these
doctors, therefore, you will tell the doctors and they will sue them
for enough money to enable them to BUY TAHITI not just retire to Tahiti
as they ruined their practice. In addition you will sue the ombudsman
for malfeasance AS THE INSURED IS PAYING HIS SALARY and he will have to
get his own lawyer as the insurance company will not pay for his
lawyer. (YOU HAVE TO TAKE THE OFFENSIVE. DO NOT LET THEM GET AWAY WITH
ANYTHING.....DO NOT SURRENDER THE POWER). it PROBABLY will not get to
this level, however, you now see you have a number of options.

I will send you some stuff written by a doctor who is also a lawyer
that is relevant to this. You will be surprised at what can be done. It
is probably worth it because the number of treatments can run into
thousands of dollars if she has a serious condition.

letter that gets the most response with the least hassle.
                                                                    
(may need some minor customizing for each case)
--------------------------------------------------                                                      MUST BE ON DOCTORS
LETTERHEAD

MEDICAL CLAIMS DEPARTMENT
XYZ INSURANCE CO.
CLAIMS DEPARTMENT / OR MANAGER

RE: (patient’s name) Policy No. #000000

Dear Ms./Mr...............

I have prescribed for my patient, Ms. .............., electrolysis
(procedure 17380) as a consequence of a hormonal imbalance resulting in
hirsutism (excessive and abnormal growth of hair in a distribution not
normal in a female... (diagnosis 704.1).

I am writing you to clarify the medical necessity of this treatment.

Hair removal is NOT cosmetic in these patients because

         A. a medical condition causes the hair growth.

        B. permanent removal of hair is necessary to restore the patient
to normal function.

        C. the physician can measure the effectiveness of medication by
monitoring the presence or absence of
            new hair growth in the areas involved only after
electrolysis therapy. Since no two patients respond
            in a similar manner to a given dose of any medication,
dosage MUST be individualized to
            minimize potential “side effects”. Electrolysis, therefore,
is instrumental in establishing the most
            effective dose of medication, consequently, the electrolysis
procedure is diagnostic as well as
            therapeutic.

        D. To achieve maximum benefits for the patient with Hirsutism it
is necessary to include electrolysis of
            the follicle concomitantly with medical therapy or else the
patient is denied the benefit of the current
            body of medical knowledge regarding treatment of her
condition. Also, it is unethical for a physician to
            withhold any information from a patient that the physician
knows to be effective.

        E. Electrolysis is standard, current medical practice and is the
only permanent treatment for hirsutism in
            this medical condition and has been certified as medically
indicated and necessary by a disinterested
            physician, Dr. ...... , a Board Certified Endocrinologist
(or Gynecologist).

        F. There is industry precedent in Massachusetts and a number of
states for coverage of this procedure.

Please contact me if I can be of further assistance

Yours truly
XXXXXXX M.D.

--------------------------------------------------
Very important phrases............

1. A hormonal imbalance resulting in hirsutism (excessive and abnormal
hair growth not normal in a female 2. Is NOT COSMETIC in these
patients. 3. A medical condition causes the hair growth. 4. Permanent
removal is necessary to restore the patient to normal function. 5. the
physician can measure the effectiveness of medication by monitoring the
presence or absence of new hair growth ONLY AFTER electrolysis therapy.
6. no two patients respond in a similar manner to a given dose of any
medication.  7. dosage MUST be individualized to minimize potential
side effects. 8. Electrolysis, therefore, is instrumental in
establishing the most effective dose of medication. 9. the electrolysis
procedure is diagnostic as well as therapeutic (this is vital because
ALL DIAGNOSTIC TESTS ARE COVERED 100% IN VIRTUALLY ALL POLICIES). 10.
To achieve maximum benefits for the patient it is necessary to include
electrolysis. 11. or else the patient is denied the benefit of the
current body of medical knowledge regarding treatment 12. It is
unethical for the physician to withhold any information from a patient
that the physician knows to be effective. 13. Electrolysis is current
standard medical practice. 14. the only treatment for hirsutism in this
medical condition. 15. has been certified as medically necessary by a
disinterested physician (this means the physician has no vested
interest in electrology other than to see the patient get the most
effective treatment with no financial gain for the physician). 16.
there is industry precedent for coverage for this procedure (in law
they often resort to “precedent” so this VIP). In addition, read the
policy to see if there is any wording that refers to “diagnosable and
treatable disorders” which this is as opposed to a “cosmetic
procedure”. Electrolysis for cosmetic purposes would be limited to
eyebrows, underarms, bikini line, raising the hairline on the forehead.
All other areas could be part of a medical problem.

Do not let them push you around. Their tactics usually involve denying
and delaying all these claims. Send all correspondence by “return
receipt requested mail” so you will have proof the letter was sent and
received. Sometimes they claim they “lost” the letter but if you get no
reply send another with a note there will be more and it is doubtful if
they lose all correspondence. Lastly you can take them to small claims
court after about only $1000 of treatments. Ins companies do not want
to go to court under any circumstance as they know nobody likes them
and the penalties are usually severe. They will try to call your bluff
every time as the know no lawyer will take a case for less than $50,000
so they figure you will drop the whole thing due to frustration.

I hope this has been useful.

WOW! James...thanks to you and your friend for all that info. i like how he/she makes a bold point to add NO BACKING DOWN...Not letting insurance companies push us around. Just wanted to add Thanks!

Just a little something to update this post string and show that insurance companies DO pay for this when all is in order(or you beat them up well enough).

11-15-2004

Hope that someone can help me with this!

I have a question that needs to be addressed and I am sure that this situation will become more prevalent in the future.

I have a client with PCOS, who has petitioned her health insurance for coverage of electrolysis treatments. She does have a letter from her OBGYN stating that electrolysis treatments are nessessary for a hirsute problem due to the PCOS. She has been given approval for the treatments.

I have never dealt with an insurance company in this manner and would like to know if someone has and what should I expect. Are there any speacial forms that I should have or get from this client? Do I ask for payment up front and have her get reimbursed herself?

Any help would be greatly appreciated!!
Electrologist A
---------------------------------------------------------------

11-19-2004
I dealt with this several years ago when there were third party payments.

At that time I did get paid and requested the insurance company send the check to the client. If they sent it to me in error I signed it over to them
I don't know if they work the same today
Electrologist B
----------------------------------------------------------------
11-20-2004

Thank You for writing back. I just found out today that the insurance company will be paying me directly. The insurance company gave me an authorization number for her treatments. They have approved my client for treatments for the next to two months then I will reevaluate and submit another request for more appointments. I was very up front about not being able to give a set amount of appointments, when dealing with a case of PCOS. They didn't have a problem with it. I must say that it really wasn't as bad as I thought it would be.

There are a lot of women out there that would come if they were covered by their insurance company. I have a second client who I had go to her OBGYN this week also to request treatment. If there is a diagnosis of PCOS, there should be no question what so ever about electrolysis treatments. I think the insurance companys would rather pay us then someone who is doing laser. Besides, we have 129 years standing behind us, that should stand for something!
Electrologist A

Just keeping the info you need if you are reading this post string in this post string...
This was posted by Harvey Grove in the PCOS forum:

Quote:

---

When females grow hair on surfaces where females usually do not grow hair but males always grow hair this is NOT COSMETIC. It is called a “male pattern distribution”....it is part of a potentially serious disorder (depending on the degree of severity of your case...mild, moderate or severe). PCOS can include infertility, adult acne, hirsutism (hair), obesity (due to insulin resistance with diabetes), cessation of menses which means the patient will develop a HYPERPLASTIC ENDOMETRIUM (this is an overgrown lining of the uterus and is recognized as a precursor to cancer of the uterus unless treated). Do NOT STOP TAKING YOUR MEDICATION UNLESS YOU TELL YOUR DOC FIRST.

There is an over-riding principle in law called “industry precedent”. It means “if one company pays ....they ALL HAVE TO PAY”. I have been paid many times by insurance companies and have photo copies of all the checks to prove it. The most was $4,280.00 by Tufts HMO. No lawyer was needed. These companies know no lawyer will take a case for less than $50,00.00 because they take a lot of time and our cases do not reach this level. We are a society of “screwers and screwees” (these are the legal terms) and insurance companies know how to use the system to delay and deny you your legal rights. Laws are made by lawyers, for lawyers, with no consideration for anyone else.

Some states have consumer laws that allow treble damages PLUS legal fees. This makes the companies take notice. You may have to pay for treatment but take them to court in the middle of treatment because small claims court has a limit on the amount of money you can sue for.Then you will continue treatment to get the rest of your money as you have established you have a legitimate claim. Anyone who changes companies to get paid by another company is making a big mistake as they can claim it is a preexisting condition and refuse to pay. They have access to your medical records and the doctors and treatments you had and that will destroy your chances of getting reimbursed.

Electrology is the “current standard medical practice” for this condition (remember this phrase as it is very important). Hair or HIRSUTISM is not a cosmetic problem....it is only one of a possible 10 symptoms of this condition. It is listed in all the medical texts of endocrinology and EPILATION therapy is reimbursed if the doctor prescribes it and he will do this if you ask him to write a letter that “epilation therapy is medically neccessary”. They do this all the time and the medical insurance code for this is Diagnosis (Dx 704.3) and Prescription (Rx 17380). The first is “hirsutism” and the prescription is the second, Electrolysis. These are the insurance codes used internationally and your doc has a code book to look it up to verify this. The code was invented by the WHO (World Health Organization).
You can contact me directly if you need more help at ..... <leftygg@verizon.net>.
Good luck .

---

I'm fighting my insurance company using the suggestions here. Right now I'm getting ready to file my second appeal. I'd like to know if a person getting state-provided insurance has the same chances, or is it going to be more difficult?

wow that is alot to go through

it seems very difficult, does the same go for laser hair removal?

my obgyn has put a laser hair removal practice in his office... my doctors just don't want to hear about insurance.
i have oxford health care, can anyone recommend a more helpful doctor to assist with this in the ny area?

It is easier for insurance companies to deny LASER work since it currently is listed with the FDA as something other than Permanent Hair Removal. On the other hand, since a doctor is more likely to be performing LASER, someone getting LASER from a doctor frequently finds a more co-operative doctor. After all, he is submitting paperwork so that HE/SHE can get paid!

In a fight with the insurance company, you will most likely loose if your proposal is LASER, however, because they have the fact that it had not proven to be Permanent Hair Removal. That doesn't mean that they won't give you hell when you switch your request to Electrolysis, but you at least won't have the Permanent Hair Removal vs Permanent Hair Reduction agrument going in their favor.

It doesn't matter who your insurance is with, the same laws apply. Of course, in the US the government programs are more likely to ignore rules because they don't care about having to pay damages in law suits. In the worst case situation, they just raise taxes to cover the loss.

It is however a fact, precedent has been set, and if one has paid, they all must pay and it is a breach of promise if they don't.

James.... what can i say !!! THANK YOU FOR ALL THAT INFORMATION.

It's wonderfully useful, and i will start the process today. I was already thinking about how i should do this as i am not a person that is afraid of asking for what is rightfully due to me. i have fought many battles with insurance companies and other consumer companies..

anyway, the point of my post was to encourage people who might not belive that they can get their electrolysis covered.

i was approved by my insurance for my ear surgery which was totally a plastic surgery and i had no intention of collection coverage for it. i paid out of pocked and the doctor called me one day to tell me that, unexpectedly so, the insurance had approved the routine claim that his office files for every procedure. he did not believe it either, but they approved it b/c it was a "genetic defect which affected the quality of my life".

Right now, I get my EMLA with a prescription, and i will ask my OBGYN to write a letter stating that he prescribes the electrolysis treatment as part of my hormonal treatment (I do have a hormonal imbalance which causes infertility at the moment and the insurance of course covers all aspects of that treatment, so this will go right along with it). i am certain that it will work as long as the doctor is willing to write the letter.

Edited from James' suggestions and information. My OBGYN will submit the following letter:



To Whom It May Concern:

I have prescribed electrolysis (procedure 17380) for my patient, Ms. I.N., as treatment of her hirsutism (diagnosis 704.3) resulting from hyperprolactinemia.

The electrolysis procedure is an essential element of this patient’s treatment. Other treatments already covered by her plan include: Levlin28 (contraceptive pill), bi-yearly MRIs, Bromocriptine, Dostinex, adult acne medication, and potentially infertility treatments.

The electrolysis procedure was prescribed for the following reasons:

- The hair growth was caused by a diagnosable and treatable medical disorder

- Permanent removal of hair is necessary to restore the patient’s normal condition

- The electrolysis procedure is diagnostic as a physician can measure the effectiveness of the medication by monitoring the presence or absence of new hair growth. Electrolysis is therefore instrumental in establishing the most effective dose of medication.

- Electrolysis is the standard current medical practice and is the only permanent treatment for hirsutism resulting from this condition.

- To achieve maximum benefits for the patient with Hirsutism it is necessary to include electrolysis of the follicle alongside medical therapy or else the patient is denied the full benefit of the current body of medical knowledge regarding treatment of her condition. Also, it is unethical for a physician to withhold any information from a patient that the physician knows to be effective.

- There are multiple industry precedents for coverage of this procedure.

The professional treating this patient is a certified member of the Pennsylvania Electrologist Association, and has treated many patients under the instructions and in collaboration with other physicians. His contact information is as follows:

Mr. Michael Buonomo
Savarese Electrolysis
1315 Walnut Street, Suite 717
Philadelphia, PA 19107
215.735.8144

Please contact me if I can be of further assistance



Yours truly
C.C., M.D.


I wanted to post it to make is easier and faster for more of us to get the rpocess going.

Ivelina,

This a fantastic letter! Please keep me informed of the outcome. Unfortunately, I have not had a patient/client who has been succesful in getting approval for insurance in many years. I will keep my fingers crossed for you and everybody else who can certainly benefit from this. Also, a big thank you to James for bringing so much attention to this much needed topic.

Yes, I will let you guys know what happens.

Aw shucks Alan, you are making me blush
Thanks for your kind words.

Really, if more doctors stood behind their patients this would not be such a rare thing. When I was a kid, my dermatologist said that I needed hair removal just to keep from living a life filled with staph infections because my ingrown hair problem on my face was not going to go away any other way. HOWEVER, he would not write that diagnosis down, and refused to help me in any way that would have gotten me the treatment I needed. After all, it would not have paid him any money for me to no longer need prescriptions from him for my constant pain and suffering. Had he helped me, I would also no longer need to see him for office visits 4 times a year.

Needless to say, I fired him.
Since I was still a kid however, I could not do much else.

WANTED: PEP TALK

I'd like to share my experiences in fighting my insurance company, and ask for some
encouragement.



6-2-04 My gynecologist wrote the following letter to my insurance company:

"Please be advised that I have prescribed for my patient, [Ms. Hir-Fem], electrolysis (procedure code 17380) due to the consequence of a hormonal imbalance resulting in hirsutism. Due to this, I am writing you to clarify the medical necessity of this treatment for my patient.

"Hair removal in this instance is NOT cosmetic for this patient because of the following:
1) This medical condition causes the hair growth.
2) As a physician, I can measure the effectiveness of her medication by monitoring the presence or absence of new hair growth in the areas involved. As no two patients respond in a similar manner, medication may need to be regulated to avoid possible side effects. Therefore, electrolysis would be diagnostic as well as therapeutic."



8-11-04 Insurance requests the following information from my GYN:

-Letter of medical necessity.
-Areas affected.
-What "hormonal condition"?
-What medications?
-What side effects of medication will observation of new facial hair growth help to avoid?
-Supply a photograph.



?-?-04 I didn't see the letter my GYN sent, but I can say the following: Areas affected are: black, coarse hair on the chin and neck; some hair on the upper lip; scattered, dark, pubic-like hair on the back; dark, pubic-like hair on the buttocks; black pubic hair on the abdomen, working its way up to the chest; dark, coarse hair on the arms and legs. I have insulin resistance. I'm taking Metformin ER. I gave my GYN a hideous photo of my beard.


9-15-04 Insurance writes:

"Request for electrolysis....denied completely because: per letter of medical necessity, there are no medical problems created by your condition. Therefore it is cosmetic and as such is not a covered benefit of the Pennsylvania Medical Assistance Program."



10-22-04 I filed a 1st level grievance and wrote:

"The removal of abnormal hair growth by electrolysis is not cosmetic; the only areas that are considered cosmetic are the eyebrows, underarms, bikini line, and raising the hairline on the forehead.
"[Insurance] paid for the medication prescribed for my condition, therefore they will also have to reimburse me for the electrolysis treatments I have been receiving."



10-26-04 Insurance writes to me, saying that they have received my 'complaint'.



11-3-04 I have to call the PA Dept of Health to have them tell Insurance that I filed a grievance and not a complaint.



11-4-04 Insurance writes:

"A committee of one or more [Insurance] staff that includes a licensed doctor or dentist, who have not been involved in the issue you filed your grievance about, will review your grievance."



12-1-04 Insurance writes:

"The first level grievance review committee consisting of a Physician Advisor who is board certified in internal medicine and a Utilization Management Nurse has decided that the denial should be upheld as not medically necessary....because information provided to [Insurance] to date is insufficient in documenting medical reasons as to why electrolysis is needed. Therefore, the requested procedure is determined to be cosmetic in nature."



1-14-05 I'm ready to file a 2nd level grievance, but my GYN wanted me to include a letter from him when I send it in. His office suggests that I call Insurance and ask for an extension on their 45-day deadline. According to the letter from Insurance dated 12-1-04, I have to file within 45 days from the date I get the notice . This would end on 1-15-05.

I call Insurance and they say the deadline was up on Jan 10th, counting from 11-26-04. Where they got that date from, I don't know. I went ahead and sent it in anyway.



1-18-05 I filed a 2nd level grievance and wrote:

"I maintain that electrolysis IS medically necessary for the following reasons:
-It was prescribed by [GYN].
-A medical condition has caused abnormal hair growth. (PCOS)
-Electrolysis is the current standard medical practice for hirsutism."

I included a letter from my GYN stating:

"As I have stated previously, electrolysis is not a cosmetic need but a medical one for [Hir-Fem]. She suffers from hirsutism which is a side effect of poly cystic ovary syndrome. Hirsutism can be defined as "an adult male pattern of hair distribution in women". Simply put, [Hir-Fem] has very heavy, coarse hair on parts of her body where a female does not generally have hair growth. In addition to this, she suffers from acne. The excess hair growth, along with the acne, can result in ingrown hairs. These ingrown hairs can result in infected hair follicles which can exacerbate both conditions.

"In addition to the physical discomforts caused by hirsutism, the emotional impact can be debilitating. The patient states that she has refused to leave her home at times because of the way she looks and feels. She tries to hide her chin when she is out in public. This is not the way any woman should have to live. She should have quality of life. The electrolysis could certainly go a long way toward providing this for [Hir-Fem]."



1-24-05 I attended the 2nd level grievance meeting and gave this speech:

"It is abnormal and humiliating for a woman to develop the facial hair pattern of a man, the same as it would be for a man to develop the characteristics of a woman. I am tired of feeling like a freak and of having to strategically hide my beard when in public.

"Hirsutism is no more cosmetic than acne is, and [Insurance] pays for acne treatments. I've had both of these conditions and can say that hirsutism is much more shameful and socially unacceptable."

They asked me where I had the hair, my age, and some medical questions. I cried through the whole thing. It was humiliating to have to tell a group of strangers, including a man, these gross things about myself. It's a good thing that I brought a copy of my GYN's letter, because they said they didn't receive anything from him.



3-4-05 Insurance writes:

"The second level grievance committee consisting of a Chief Medical Officer who is board certified in family practice, a Utilization Management Nurse and a [Insurance] Member has decided that the decision to deny electrolysis be upheld...[Insurance] is required by contract with the Commonwealth of Pennsylvania to cover medical services that are medically necessary...[Insurance] has not been provided with documentation to support a medical need."



3-14-05 I requested an external review and a copy of the company's criteria for a medical necessity.



3-18-05 Insurance tells me that they sent the request to the PA Dept of Health.



3-21-05 PA Dept of Health writes to me that they have assigned my grievance to "an independent and external review organization called a Certified Review Entity (CRE)."

According to their rules, I have to send a copy of what information I give to the CRE to Insurance also. Insurance is also supposed to send a list of what they send to the CRE to me within 15 days that they received my appeal request. I have never received this.



3-31-05 I sent the CRE the following:

-A copy of my Dr.s diagnosis of Hirsutism and PCOS.
-My GYN's prescription for electrolysis.
-My letters requesting 1st and 2nd level grievances.
-GYN's 2nd letter.
-Comments I made at the 2nd level meeting.
-5 X 7" photo of my beard.



4-14-05 CRE writes:

"The health plan's original denial is: Upheld"

The reviewer is board certified in OB/GYN and Reproductive Endocrinology and Infertility. Their list of credentials is intimidating; having won awards, written over 70 articles, being a member of many pro medical organizations, and being the Director of this and that.

The reviewer wrote:

"The treatment is not medically necessary. According to the American Society for Reproductive Medicine Practice Committee, "Hirsutism is a common complaint, often of significant cosmetic concern, usually resulting from increased androgenic activity. Hirsutism usually does not signify major pathology..." ...Hirsutism is considered a "cosmetic concern" by the ASRM- "Patients who suffer from hirsutism require long term follow up and emotional support.""



As a side point, I received from Insurance their definition of medical necessity (after my deadline to file info with the CRE), which lists 3 standards for a covered benefit. They say if any one of them is satisfied, then the service will be considered medically necessary. The second is: "The service or benefit will, or is reasonably expected to reduce or ameliorate [improve] the physical, mental, or developmental effects of an illness, condition, injury, or disability."



5-19-05 I ask for HELP!!! Do I have a chance in court?

Dear HIR-FEM,

Unfortunatley your story is not unique. I have been an Electrologist in Pennsylvania for 25 years and it has been at least 15 years since I have had one of my patients get compensation from the insurance companies. It is very frustrating to say the least!

You didn't mention how you are doing with your treatments. Have you been getting results?

i, too am from PA, and have been denied twice for payments of electrolysis. i've requested an external review and am awaiting the results of that. The only thing that i've noticed in your timeline is that you never said that electrolysis is absolutely necessary to confirm you are taking the correct medication for your medical condition (PCOS). in order to know your body is not creating more, new hair, you need to treat existing hair through electrolysis. all meds react differently to people. how do you suppose you are taking the right meds? this might be something you would like to bring up. it is medically necessary for electrolysis to be performed in order to treat existing hairs and to make sure no new hairs are growing for the confirmation that you are taking the correct meds. i have yet to hear from my insur. co. in reference to my external review. (thanks to James..i actually sound like i know what i'm talking about!). good luck. we all need it!!

I assume that your electrolysis costs to date still fall under the limits of small claims cases in your area. You have followed their procedure, and now it is time to file your "Breach of Promise" claim in small claims court. It will cost you only the filing fee and the cost of showing up to court. It will help you if your doctor would come as well, but a notarized statement from your doctor and contact info for the judge is often accepted as his testimony.

They will still wait till the last possible minute to pay you. Waiting to see if you are serious enough to pay the additional fee to have the court warn them of siezures and garnishments if they don't pay up in 90 additional days. In this way, although they still end up paying you, they make you wait 6 months after the court case to give you dime one.

I've had 30 hours of the blend performed on my beard, at a cost of $2550. This began in July of '04 and ended in Feb '05 when I ran out of money. I figure that the total cost of removing my beard will run over $10,000. Then there's my other body areas...

Unfortunately, the front of my chin still needs more work, as it is noticeably gray from the combination of my being pale white and having a black beard. Even with opaque concealer applied I can still see it.

Seeing as I'm not going to be able to be treated in a while, I'm really tempted to tweeze it all off just one day to reduce the grayness. I'd hate to do this, because I stopped tweezing back in Jan '04, and I don't want to mess up my hairs' growth cycles and make all that beard unavailable when I do return to getting treatments. Besides, if tweezing makes the hairs stronger, then that's no good.

If you file a small claims case against your insurer, you will have a date for sometime in the next 30 to 60 days. Your judgement will take effect in 60 to 90 days, and if they really wait till you file for collection action, you will have money in 180 days.

As I've stated before, I've filed and lost three appeals. On the letter I received from the third denial, it states that I have 60 days (from the day I receive the letter) to initiate an "appeal of the decision to a Court of Competent Jurisdiction". What does this mean? What am I supposed to do? Who do I call?

The letter is dated 4-14-05; 60 days from that is 6-13-05.
I talked to one lawyer, who referred me to a second lawyer, who referred me to a third lawyer, who referred me to a fourth lawyer, who I haven't bothered calling. Can I do this alone? And, what do I do?

I went to lawyers.com and got a list of 4 lawyers in Allegheny County who do health insurance law. I called one. He told me to call Neighborhood Legal Services. They told me that they don't do that sort of thing and that I should call Pennsylvania Insurance Something-Or-Other. So I went online and got the number of the PA Insurance Department. While I'm waiting for them to call back, I called another lawyer from lawyers.com. He told me to call the external review people to find out if the 60-day period is valid. They said yes and that I can't get an extension, and I should call the Allegheny County Bar Association. Their recording says that they want $25 for a 30-minute consultation. I hung up because I'm not going to pay $25 to hear someone tell me they can't help me.

HELP!!!

You have been told several times to file a SMALL CLAIMS COURT CASE. You know, like they show on Judge Judy and People's court. Call your local court house, or court clerk's office and they will tell you where your SMALL CLAIMS COURT OFFICE is, and what their dollar limits are.

In New York State, the limit is Five Thousand US Dollars. Anything higher and you have to sue in regular civil court. You want Small Claims Court, because it only costs you about $20 to file the case, and you represent yourself. THEY ON THE OTHER HAND must hire a lawyer and show up for the case, or loose a default judgement, and the court will make them pay or loose their license to sell insurance in your state.

Since your profile says you live in Pennsylvania, I can direct you to start your search at this web site.

http://www.consumeraffairs.com/consumerism/small_pa.html

Small Claims Court General Information for The State of PA

Dollar Limit:: Philadelphia Municipal Court: $10,000; District or Justice Court: $8,000. Where To Sue: Where defendant resides or is found or where breach or injury occurred. Corporation resides where it has principal place of business.
Service: Certified or registered mail, sheriff or court- approved disinterested adult.
Hearing Date: Municipal Court: Set by court. District or Justice Court: 12-60 days from service.
Attorneys: Allowed; required for corporations, except when corporation is defendant and claims is for more than $2,500 (Philadelphia Municipal Court).
Transfer: Municipal Court: If defendant counterclaims over jurisdictional limit, case tried in Court of Common Pleas. District or Justice Court: No provision.
Appeals: By either side for new trial or a trial by jury; to Court of Common Pleas within 30 days.
Special Provisions: District Justice Court: no real estate cases; court may order installment payments; court may order arbitration. Municipal Court: no jury trial. If claiming more than $2,000 for injury to self or property, will have to submit a verified (signed under oath) statement of claim (Philadelphia Municipal Court).

By this, I can see that you can sue for up to $8,000 with no lawyer, and they must attend the hearing that will be set for 12 to 60 days after you file.

This is from:
http://www.cmu.edu/policies/Landlord-Tenant/djcourt.htm

In Pennsylvania, landlord-tenant cases are usually filed in District Justice Court. You may have heard this kind of court referred to as Small Claims Court. Filing suit in District Justice Court is a relatively simple proccess. You don't need a lawyer to represent you. You can file a claim in District Justice Court as long as your damages (i.e., amounts claimed) are under $8,000. A filing fee (ranging from $37.50 to $82.50, depending on the amount in dispute) is required. If you win your case, the other party will usually be required to reimburse you for the filing fee.
There are several District Justice Court offices in Pittsburgh; each one has jurisdiction over a certain geographic area. To determine which office has jurisdiction over your claim, call the District Justice Court Administrative office at 412-350-5485. Once you've determined the appropriate office, you can start your action by filing a claim there, stating what the dispute is and what your damages are. The District Justice will schedule a hearing where all parties will have the right to tell their stories, present witnesses and documents and question each other's witnesses. After the parties are done presenting their cases, the District Justice will make a decision, either at the end of the hearing or by mail. (If a hearing is scheduled and you don't show up, you automatically lose.)

If you don't agree with the decision, you can file an appeal with the Court of Common Pleas within 30 days of the District Justice's decision. A Common Pleas Court case is a more formal process and requires following all the regular court rules and procedures. You will probably want a lawyer to advise you if you file an appeal.

Presenting Your Case.You should prepare for your hearing with the District Justice by thinking about your case and gathering all the evidence you can to support your side of the story. Evidence can take the form of your own testimony, the testimony of others with relevent knowledge, and documentary evidence. For instance, if your case is about not receiving your security deposit, your evidence might consist of your own and your rommate's testimony that the apartment was clean and undamaged when you moved out, photos taken of the clean apartment, and receipts for payments for cleaning services or cleaning products.

If you can't afford an attorney, you can obtain low-cost legal assistance from the Allegheny County Bar Association

James,

Thank you for taking the time to write that great letter. My problem is that I'm a transsexual, have been living full-time for a year, and while I've removed a lot of facial hair w/electroylsis, I still have a fair way to go. Do you know if there's insurance precedent for covering electrolysis for TS? Do you know how I'd need to re-word the letter you wrote to get it covered?

Kathryn

That one is harder, as your doctor is not saying that the hair removal is to correct a problem, or help to see the progress of ongoing treatment. If however you have a co-operative doctor, you may give it a go, because if your insurance covers any part of treatment for transsexualism, they must treat all phases of the treatment within reason, and hair removal is very basic to living as a woman. They may not pay for your new chin (no one said you have to be a pretty woman) but hair all over your face is unacceptable as a woman (you have to at least pass as a credible woman for your own safety)

I don't have time to write much now, but that is what you have to work with. Good luck.

On June 16th, I filed suit. The secretary/receptionist seemed very confused by my request, and said, to paraphrase, "You lost three grievances and you think you can win a suit?" (I thought her job was to have me fill out a form, not question my sanity.)

The District Justice sent a letter to me stating that the Insurance company has said that they will defend themselves. I hope they don't show up, because the chance of me losing my composure is very high. I'm going to arm myself with all the ammo suggested in this post. When it's over, I'll post the outcome.

Actually, they are hoping YOU don't show up.

It will help if you have your doctor's co-operation here. Although I understand that most won't show up and testify for you, it is in your best interests to find out how your small claims court will accept absentee testimony from a doctor. Some will take a letter and an invitation to call the doctor while in chambers, others will take a notarized statement from the doctor.

Remember, to them this is all about stone walling you. These are the people who refuse to pay for your life saving surgery, hoping that you die before you successfully sue them to get it done, all while taking out a secret life insurance policy on your life so that they actually make money on you when you die prematurely. Take nothing but a full judge, not a mediation, an actual judge and a full hearing. If you have the chance, go for a jury trial. Can you find a jury sypathetic to an insurance company?

Federal or state district court? Not sure about your state's rules, but if you're in federal court you must demand a jury trial at the proper time:

http://www.law.cornell.edu/rules/frcp/Rule38.htm

Most of these cases will be in your area's Small Claims Court Division. What ever is the place where landlord/tennant disputes are settled. This puts you in the driver's seat, because you are the one who files. You don't need to pay a lawyer, but THEY DO HAVE TO PAY FOR LEGAL REPRESENTATION. Your cost to sue them, less than $50 plus any lost work time for the hearing(s)

You effectively put the insurance company in the situation that it costs them money to fight your suit, instead of their obstanance costing you money while you wait.

I really don't understand why people are not comprehending that I am talking about your local version of the court shown on shows like Judge Judy, The People's Court, Judge Joe Brown, and stuff like that.

Here are the highlights from my hearing. They are not necessarily in order and definitely not complete.


7-20-05 I started off by saying that I have Polycystic Ovarian Syndrome and insulin resistance, both of which result in hirsutism, which is a male hair pattern on a woman. The insurance company's definition of medical necessity says that they will cover a service that "will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability." I gave him a copy of this, along with both letters from my gynecologist (see my above timeline that I posted on Thu May 19 2005 06:08 PM, under the dates of 6-2-04 and 1-18-05).

Along with that I gave him a copy of a note from my PCP (I put a '?' by the words I wasn't sure of) stating: "Miss? [Hir-Fem] has PCOS with high DHEAS and testosterone levels. This causes severe? hirsutism and has caused her emotional distress. She has had CT scans of abd? and pelvis which are negative? for any masses and will need hormonal intervention? and electrolysis to treat and ameliorate her condition."

I wanted to show him my beard photo, but he said that wasn't necessary.