Trying to figure out what the process would be for getting my insurance to cover facial feminization surgery. Would my Plan Document have more specific information about that than my Summary Plan Description?

I am trying to figure out whether my health insurance plan will provide coverage for facial feminization surgery. I obtained a copy of my plans Summary Plans Description which lists a lot of different categories of healthcare. One of them is "Gender Dysphoria", and it says under it that a prior auth is required before any surgical procedures are covered.

I talked to an "Advocate" with my health plan and they said that I would need a specific code, but from what they can see cosmetic surgery is not covered and facial feminization surgery would be only be covered if deemed medically necessary with a prior auth. That leaves me questioning whether my plan would ever consider facial feminization surgery as being medically necessary or if there are specific criteria for it being medically necessary.

I found on one website it said that you can find this information in a "Certificate of Coverage", that you can request from your insurance provider, which should lay out clearly what procedures are covered under a plan and what is required for the prior auth to be approved. I noticed some places used this term while others didn't. I asked my insurance provider for it and they didn't seem to know what it was.

So now I'm reading on the DOL website that all health insurance plans should have a "Plan Document", which the SPD summarizes, and it should explain everything in the plan in a harder to understand more legalese format.

So my question is, would this document list specifically what procedures are covered and what is required for a prior auth for those procedures? Or would it mainly be legalese about other information regarding the plan?

ETA: I'm in the US, in NC.

submitted by /u/soowhatchathink
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