Medical Insurance


  • In Germany, the prostheses are usually paid for by medical insurance companies. (see 'Germany'  here below for information specifically relevant within Germany. )
  • Two people in the USA have reported being partially reimbursed by their insurance companies.


Process (also for orders within Germany)

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 Phase4 or a t2 Simple. Please send me your name and address and request a Cost Quote.

I ask you to let me know how your insurance company responded. All information gathered helps me to encourage insurance coverage (the cost estimate wording, licensing and official terminology for various aspects of the project).



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 (ie: will need to be periodically replaced/repaired or renewed, with associated costs.), and shows that they are registered medical devices.

 

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.

 



Germany

The following is specifically relevant to people with medical insurance coverage within Germany.

 

 

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

 

 

To have your prosthesis paid for by your insurance in Germany, you need a note from your doctor, and a cost quote from me (the quote includes all required information for cost coverage in Germany).

 

If your insurance company issues you a denial, I suggest you send them a written objection (Widerspruch einlegen).

 

 

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).

 

 

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