Medical Insurance


t2 prosthetics is not in communication with any insurance companies. I don't have the resources or information to work on individual prostheses being covered by individual medical insurance companies. 



If you wish to receive a cost estimate (pdf) to send to your medical insurance company for a t2 prosthesis, you can send me your name and address and request a Cost Quote.

I ask you to let me know how your insurance company responded.



The Cost Quote includes: the cost, a short description of the prosthesis and its proposed medical use (to decrease genital dysphoria), that it is not a replacement for phalloplasty or other genital reconstructive surgery which the wearer may choose to undergo, that the prosthesis is a temporary product with parts that break down over time (would need to be periodically replaced/repaired or renewed, with associated costs.), and includes the medical device registration numbers and other relevant information.

 

Should your insurance company cover the costs, the order process will remain the same - You will still need to pay the deposit at time of order, and I must receive the payment in full (generally) one month before mailing your prosthesis.



Specifics to Germany


Thanks to everyone who shared their ideas, discussions, letters of denial and acceptance from their health insurance companies so far.



t2 prostheses are often paid for by medical insurance companies in Germany, but please expect a long process with a lot of back and forth.




The information I supply in the Cost Quote is the information the insurance companies need from me.


Please understand that I don't have the resources to communicate directly with insurance companies, and I can’t take on the work of having your prosthesis covered by a medical insurance company. 


Over the years people have reported their experiences and sent copies of their acceptance letters. I have a good overview of reasons /methods used in initial denial of payment. Please keep this in mind and feel free to ask me questions while in communication with your insurance company.



 


If you want to help increase cost coverage from insurance companies, please share your ideas or information with me   info@tyron2.net





Process (cost coverage in Germany)

 


To have your prosthesis paid for by your insurance in Germany, you need a note from your doctor, and a cost quote from me. You send both of those to your health insurance company.


 


If your insurance company issues you a denial, you can send them a letter of objection to the denial (Widerspruch einlegen).


 


Lately, people have been reporting that their insurance company says they would "gladly cover the costs but needs  X  paper/number/more information from me".  Each time the information requested is something new.

I want to stress here that:  The information I supply in the Cost Quote is the information the insurance company needs from me. I cannot offer more involvement at this time.


For clarification: I sell the prostheses/ samples of the current design to fund the design work. As long as t2 prosthetics is a design project, my time and resources are needed for the design.






The following is a compilation from a few years back. The information may still be relevant: 



Common explanations for denial with corresponding counter-arguments

(Quotes are in German because you will be corresponding with them in German, and I prefer to give you the original texts)

 

1: Reason: 

‘The prosthesis is not in the medical device directory (Hilfsmittelvezeichnis)*.’

 

Counter-argument:

 

About the medical device directory

„Alle von der Leistungspflicht umfassten medizinischen Hilfsmittel sind im Hilfsmittelverzeichnis der gesetzlichen Krankenversicherung gelistet (§ 139 SGB V). Dabei ist das Hilfsmittelverzeichnis keine Positivliste, sondern eine unverbindliche Empfehlungshilfe. In der Praxis heißt das, dass auch Hilfs- mittel, die (noch) nicht im Hilfsmittelverzeichnis gelistet sind, durch die GKV erstattungsfähig sind (vgl. BSG-Urteil vom 29.09.97, AZ.: 8 RKn 27/96 und BSG-Urteil vom 31.08.2000, AZ.: B 3 KR 21/99).“

 

Quoted from

http://www.eurocom-info.de/fileadmin/freigabe/user_upload/Dokumente_eurocom/pdf_Dokumente_eurocom/Positionspapier_Weg_der_Zulassung_von_Hilfsmitteln.pdf

 

 

 

2. Reason: 

‘It’s an epithesis not a prosthesis.’ OR ‘It’s a prosthesis not an epithesis.’

 

Counter-argument:

 

(Exactly which term best fits is unclear, but either way) it’s a "substitute body part" (Körperersatzstück).

 

Law on coverage of medical devices

„(1) Versicherte haben Anspruch auf Versorgung mit Hörhilfen, Körperersatzstücken, orthopädischen und anderen Hilfsmitteln, die im Einzelfall erforderlich sind, um den Erfolg der Krankenbehandlung zu sichern, einer drohenden Behinderung vorzubeugen oder eine Behinderung auszugleichen, soweit die Hilfsmittel nicht als allgemeine Gebrauchsgegenstände des täglichen Lebens anzusehen oder nach § 34 Abs. 4 ausgeschlossen sind.“

 

Quoted from

http://www.gesetze-im-internet.de/sgb_5/__33.html

 

 

3. Reason: 

‘Cost coverage is excluded according to SGB 5 § 34 Abs. 4 with reference to:

 

"Ausgeschlossen sind insbesondere Arzneimittel, die überwiegend zur Behandlung der erektilen Dysfunktion, der Anreizung sowie Steigerung der sexuellen Potenz"’

 

Quoted from

http://www.gesetze-im-internet.de/sgb_5/__34.html

 

Counter-argument:

 

The prosthesis is not an „Arzneimittel“. Arzneimittel means pharmaceutical (= medicine, drug). The section refers to „Arzneimittel“ and not to „Hilfsmittel“.  The prosthesis is a „Hilfsmittel“(Körperzusatzstück/ Prothese oder Epithese).