Medical Insurance Coverage

In order to increase coverage in general, I conform to EU-wide rules and regulations for the production and sales of medical devices. The t2 Phase4 is a registered medical device in accordance with the EU Medical Device Regulation (EU) 2017/745).


Please Note


1. t2 prosthetics is not in communication with any insurance companies. I am happy to assist you where I can, but I don't have the resources to communicate directly with your insurance company.


2. I am paid by you, and not by the insurance company. The insurance company pays you, and you pay me. It’s your name on the invoice, not that of the insurance company.

 

3. 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, I must receive the payment in full (generally) one month before mailing your prosthesis.

 

 


If you wish to receive a Cost Quote for a t2 prosthesis, please send me your name and address and request a Cost Quote.


The Cost Quote includes a short description of the prosthesis, certification and registration, a few points on the production process, and the cost.

If you are in Germany, I will also send you an attachment noting how the t2 prosthesis matches the criteria outlined in the ‘medical device listing for the German statutory health insurance association’. („GKV-Hilfsmittelverzeichnis 35.27.01.0001 Angang Kostenvoranschlag")

If you are not in Germany, the Cost Quote I send you will be in English, German, or French and the wording a bit different (more universal). Feel free to give me country specific information that I may be able to ad to your Cost Quote.

 


Process for cost coverage in Germany (likely similar in other countries.)


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 hand both of those to your health insurance company.



Usually, the insurance company says "no". They always give a reason, but the reasons are rarely valid.  

In Germany, you respond with a letter of objection to the denial (Widerspruch einlegen).Feel free to send me a copy of the rejection letter and ask me for ideas for your counter argument.




As far as I know, you first need to go through the steps for any sort of trans* related cost coverage. As of January 1st 2022, the ICD-11 applies in Germany. Changes may come as a result of the new categorisation and terminology. Please let me know if you have information to share about that.


 


Useful information (in German, for reimbursement in Germany):

 

Seite 55, ‘Penis-Hoden-Epithesen’

https://www.gkv-spitzenverband.de/media/dokumente/krankenversicherung_1/hilfsmittel/fortschreibungen_aktuell/2018_2/HiMi_Produktgruppe_35_Epithesen_03-2018.pdf

 

 

Seite 38,  Versorgung mit technischen Produkten / Hilfsmitteln’

https://www.mds-ev.de/fileadmin/dokumente/Publikationen/GKV/Begutachtungsgrundlagen_GKV/BGA_Transsexualismus_201113.pdf




Links to information about cost coverage in general (in German, for within Germany)

 

https://www.verbraucherzentrale.de/wissen/gesundheit-pflege/krankenversicherung/hilfsmittel-beantragen-wie-geht-das-richtig-6895

 


https://www.verbraucherzentrale.de/wissen/gesundheit-pflege/krankenversicherung/hilfsmittel-was-tun-bei-ablehnung-der-krankenkasse-62294

 


https://www.bundesgesundheitsministerium.de/service/begriffe-von-a-z/k/kostenerstattung-in-der-gkv.html



The following is a compilation from a few years back. The information is still 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


https://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).

 

 


 

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


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