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Health Insurance Coverage of Gender-Affirming Top Surgery in the United States

Ngaage, Ledibabari M. M.A.Cantab., M.B., B.Chir.; Knighton, Brooks J. B.S.; McGlone, Katie L. B.S.; Benzel, Caroline A. B.S.; Rada, Erin M. M.D.; Bluebond-Langner, Rachel M.D.; Rasko, Yvonne M. M.D.

Plastic and Reconstructive Surgery: October 2019 - Volume 144 - Issue 4 - p 824-833
doi: 10.1097/PRS.0000000000006012
Breast: Special Topic
Free
Video Discussion
Press Release

Background: Despite the medical necessity, legislative mandates, and economic benefits of gender-affirming surgery, access to treatment remains limited. The World Professional Association for Transgender Health (WPATH) has proposed guidelines for transition-related surgery in conjunction with criteria to delineate medical necessity. The authors assessed insurance coverage of “top” gender-affirming surgery and evaluated the differences between insurance policy criteria and WPATH recommendations.

Methods: The authors conducted a cross-sectional analysis of insurance policies for coverage of top gender-affirming surgery. Insurance companies were selected based on their state enrollment data and market share. A Web-based search and individual telephone interviews were conducted to identify the policy. Medical necessity criteria were abstracted from publicly available policies.

Results: Of the 57 insurers evaluated, bilateral mastectomy (transmasculine) was covered by significantly more insurers than breast augmentation (transfeminine) (96 percent versus 68 percent; p < 0.0001). Only 4 percent of companies used WPATH-consistent criteria. No criterion was universally required by insurers. Additional prerequisites for coverage that extended beyond WPATH guidelines for top surgery were continuous living in congruent gender role, two referring mental health professionals, and hormone therapy before surgery. Hormone therapy was required in a significantly higher proportion of transfeminine policies compared with transmasculine policies (90 percent versus 21 percent; p < 0.0001).

Conclusions: In addition to the marked intercompany variation in criteria for insurance coverage that often deviated from WPATH recommendations, there are health care insurers who categorically deny access to top gender-affirming surgery. A greater evidence base is needed to provide further support for the medical necessity criteria in current use.

Baltimore, Md.; and New York, N.Y.

From the Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine; and New York University Langone Health.

Received for publication February 15, 2019; accepted April 9, 2019.

Video Discussion by Loren Schechter, M.D., is available for this Article.

Disclosure:The authors have no financial interest to declare in relation to the content of this article.

A Video Discussion by Loren Schechter, M.D., accompanies this article. Go to PRSJournal.com and click on “Video Discussions” in the “Digital Media” tab to watch.

Yvonne M. Rasko, M.D., Department of Plastic Surgery, University of Maryland, 22 South Greene Street, Baltimore, Md. 21230, yrasko@som.umaryland.edu, Instagram: @dr_millie_n

Gender-affirming surgery is a medically necessary procedure to treat gender dysphoria.1 It is not a single procedure, but a complex team process involving multiple medical, mental health, and surgical specialities working in tandem. The reconstructive operations involved in gender affirmation, alongside medical necessity criteria, are outlined in the standards of care by the World Professional Association for Transgender Health (WPATH) (Table 1).1 Often, the first (and at times, the only) operation that patients undergo in transition is “top” surgery. This refers to bilateral mastectomy (masculinizing chest surgery), performed in transmen and nonbinary individuals, and breast augmentation (feminizing breast surgery), performed in transwomen and nonbinary individuals.2 These procedures have been shown to improve quality of life and reduce symptoms of gender dysphoria in transgender individuals.3–6

Table 1. - World Professional Association for Transgender Health Suggested Criteria for Standards of Care
Masculinizing chest surgery
 I. Persistent, well-documented gender dysphoria
 II. Capacity to make a fully informed decision and to consent for treatment
 III. Age of majority in a given country (if younger, follow the SOC for children and adolescents)
 IV. If significant medical or mental health concerns are present, they must be reasonably well controlled.
 V. Hormone therapy is not a prerequisite.
Feminizing breast surgery
 I. Persistent, well-documented gender dysphoria
 II. Capacity to make a fully informed decision and to consent for treatment
 III. Age of majority in a given country (if younger, follow the SOC for children and adolescents)
 IV. If significant medical or mental health concerns are present, they must be reasonably well controlled.
 V. Although not an explicit criterion, it is recommended that transfeminine patients undergo feminizing hormone therapy (minimum 12 mo) before breast augmentation surgery.
S
OC, standard of care.

The greatest barrier to accessing health care treatment, as reported by the transgender population, is cost.7 Therefore, there is increased reliance on insurance companies to facilitate access to treatment. Legislation placed in 20148,9 has prohibited transgender-specific exclusions in health care insurance coverage. This legal shift, in addition to the growing consensus regarding the medical necessity of gender-affirming procedures,1,10,11 may account for the 155 percent rise in gender-confirmation surgery.12 However, this statistic is reported by a survey and thus likely represents a conservative estimate of the true increase. Furthermore, coverage of transition-related surgery is supported by evidence that demonstrates the cost-effectiveness of such policies.13

Nonetheless, a survey7 noted that more than half (55 percent) of respondents who sought coverage of gender-affirming surgery were denied. In addition, rates of transition-related coverage differed by gender. The same study reported that transmasculine individuals were more likely to report being denied insurance coverage of surgery compared to their transfeminine counterparts. However, this survey is limited, as it does not report the proportion that met the medical necessity standard for preauthorization of these operations. Insurance policies often show variability in coverage, do not have standardized criteria, and do not conform to accepted medical guidelines.14,15 This can result in difficulty interpreting and meeting the medical necessity benchmark. Although the WPATH standards of care are flexible, they offer guidance and standardized criteria for medical necessity. Currently, the literature is void on insurance policy criteria for top gender-affirming surgery and/or how they relate to WPATH standards of care.

This study aims to evaluate the variability in insurance coverage and policy criteria for gender-affirming breast/chest surgery, and assess gender-related disparity in health care coverage. Furthermore, we aim to bring clarity to coverage practices so both surgeons and patients may be better informed to advocate for treatment.

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PATIENTS AND METHODS

Insurance policies for coverage of gender-affirming top surgery were collected from U.S. health insurers in December of 2018 to January of 2019. The providers were selected based on state enrollment data16 and company market share, as reported by the National Association of Insurance Commissioners.17 A Web-based search identified the policies on the corresponding company’s website. If a policy was not located online, we communicated with the individual company directly through a phone call, and if a lack of established criteria for surgical intervention was confirmed, the insurance company was deemed to not have a policy for gender-affirming breast/chest surgery. Policies were categorized into three groups based on coverage status: never covered, coverage on a case-by-case basis, and preauthorized coverage. Case-by-case status was defined as a policy established for coverage but without standardized criteria and coverage determined only with specific patient details. The insurance policies with generalized criteria were analyzed and the criteria abstracted.

Data were compiled and analyzed in Microsoft Excel (Microsoft Corp., Redmond, Wash.). The chi-square test was used as appropriate to calculate significance in differences between categorical data. Statistical significance was defined as a value of p ≤ 0.05.

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RESULTS

Fifty-seven insurance companies were evaluated for the policies regarding coverage of gender-affirming top surgery. Of the 57 companies evaluated, 96 percent possessed a policy that provided coverage. One insurer (Family Health West Virginia) did not have a policy regarding top gender-affirming surgery.

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Coverage

The coverage of breast/chest surgery was evaluated by procedure (Figs. 1 and 2). Bilateral mastectomy (transmasculine surgery) was covered by significantly more insurers than breast augmentation (transfeminine surgery) (96 percent versus 68 percent; p < 0.0001). The insurers that did not provide coverage for transfeminine breast surgery listed the procedure as “not medically necessary.” Policies were compared to the WPATH guidelines on standards of care1 and great deviation was found. Only two insurance companies (4 percent) (i.e., Horizon Blue Cross Blue Shield of New Jersey and Moda Health) possessed policy criteria consistent with WPATH recommendations.

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

Half of the insurance companies assessed held a policy with generalized criteria for preapproval breast augmentation (n = 30) compared with the majority of policies on bilateral mastectomy (n = 53) (53 percent versus 93 percent; p < 0.001). In addition to a universal requirement of a diagnosis of gender dysphoria congruent with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, standards, six recurrent criteria common to both transfeminine and transmasculine operations were identified.

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Age

WPATH uses the term “age of majority in any given country.” This age is not necessarily 18 years and can vary from state to state. There was no consensus on age requirement in policies with generalized criteria for either procedure. Only one (Gateway Healthcare) followed WPATH recommendations. The majority required the candidate to be 18 years or older for breast augmentation (transfeminine) and bilateral mastectomy (transmasculine) operations (80 and 85 percent, respectively), whereas a small proportion would consider younger patients on a case-by-case basis with physician assessment or guardian consent or did not have a specified age requirement (Table 2).

Table 2. - Number of Insurance Companies That Requested Specific Coverage Criteria in Transfeminine and Transmasculine Top Surgery
Transfeminine (%) Transmasculine (%) p
No. 30 53
Age 0.7170
 ≥18 yr 24 (80) 45 (85)
 Case-by-case 3 (10) 5 (9)
 Age of majority 1 (3) 1 (2)
 None specified 2 (7) 2 (4)
Minimum time with GD diagnosis 0.7517
 6 mo 25 (83) 40 (75)
 12 mo 1 (3) 3 (6)
 24 mo 4 (13) 10 (19)
Continuous living as gender 19 (63) 29 (55) 0.5967
 12 mo 18 (60) 27 (51)
 24 mo 1 (3) 2 (4)
Hormone therapy 27 (90) 11 (21) <0.0001*
 12 mo 18 (60) 11 (21)
 18 mo 1 (3) 0 (0)
 24 mo 5 (17) 0 (0)
 No time given 3 (10) 0 (0)
No. of referring MHPs 0.2059
 One 24 (80) 34 (64)
 Two 6 (20) 19 (36)
G
D, gender dysphoria; MHPs, mental health professionals.
*
Statistically significant.

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Duration of Gender Dysphoria Diagnosis

Although a diagnosis of gender dysphoria was required for all insurers, not all insurers requested a minimum duration congruent with that of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria (i.e., 6 months). A similar proportion of policies for transfeminine and transmasculine top transition surgery deviated from this standard (17 percent versus 25 percent; p = 0.5777). Other durations requested by insurance companies were 12 and 24 months (Table 2).

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Continuous Living in Congruent Gender Role

Almost two-thirds of insurers listed continuous living in a gender role congruent with their gender identity as a criterion for feminizing top surgery (breast augmentation) compared to half of the policies covering masculinizing top surgery (bilateral mastectomy) (63 percent versus 55 percent; p = 0.5967). This was split between 12 and 24 months’ duration, with the majority of third-party payers requesting the former (Table 2).

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Hormone Therapy

A significantly higher proportion of policies covering breast augmentation than bilateral mastectomy required patients to have received hormone therapy before surgery (90 percent versus 21 percent; p < 0.0001). All masculinizing policies required a duration of 12 months before surgery, whereas the duration of hormone therapy varied for feminizing policies (Table 2). In addition, seven feminizing policies (23 percent) required evidence showing inadequate breast tissue development following hormone therapy.

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Referring Mental Health Professionals

All policies required evaluation by a mental health professional. Although one mental health professional is the number recommended by WPATH for referral of top gender-affirming surgery, the number required for referral varied between policies. The majority of policies in both transfeminine and transmasculine top surgery required the WPATH standard of one mental health professional (80 percent versus 64 percent; p = 0.2059), and a small number of policies for both requested referral from two mental health professionals (Table 2).

In addition, some policies listed specific credentials required of the referring mental health professional(s). Almost two-thirds of policies for transfeminine and transmasculine surgery had a specific qualification requirement that corresponded to that detailed by WPATH (63 percent and 64 percent, respectively). Each mental health professional is required to submit a referral letter. A higher proportion of policies covering bilateral mastectomy compared to policies covering breast augmentation requested a specific referral letter format that corresponded to recommendations by WPATH (58 percent versus 43 percent; p = 0.2713).

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Other Mental Health Concerns

Of those who held policies that included coverage of transfeminine and transmasculine procedures, 21 companies (the same in both) included additional mental health criteria (70 percent and 40 percent, respectively) (Table 3).

Table 3. - Considerations of Other Mental Concerns in Insurance Policies Covering Gender Affirming Breast/Chest Surgery
Consideration No. of Insurers
Any significant mental health concerns are well controlled 13
Patient has ability to make fully informed decisions and give consent for treatment 2
Not a symptom of another disorder 21

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Reversal

Of the third-party payers who held policy that included breast/chest surgery, a smaller proportion of insurers would consider coverage of reversal of transfeminine surgery compared to transmasculine surgery; however, this did not reach significance (23 percent versus 33 percent; p = 0.7773). Detailed summaries of insurance coverage of the reversal procedures for top masculinizing and feminizing operations are shown in Figures 3 and 4.

Fig. 3.

Fig. 3.

Fig. 4.

Fig. 4.

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Nipple Reconstruction or Revision

With regard to transmasculine chest surgery, a quarter of patients undergo an additional procedure to revise the nipple-areola complex to correct complication or improve the aesthetic results18; however, it is often deemed cosmetic. Therefore, insurance policies were evaluated for coverage of surgery to further revise or reconstruct the nipple-areola complex after transmasculine chest surgery. Of the 55 companies that covered masculinizing chest surgery, over one-third would cover the procedure albeit with caveats [n = 21 (38 percent)], and an additional 18 percent would cover without prior preauthorization.

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DISCUSSION

We have highlighted the great variability in coverage and medical necessity criteria for gender-affirming “top” surgery across insurance companies. In contrast to previous survey findings,7 significantly fewer policies provided coverage for feminizing breast surgery than for masculinizing chest surgery. Furthermore, policy criteria diverged from the standards of care outlined by WPATH1 in multiple areas in almost all policies. In addition, nipple reconstruction is considered an inalienable part of chest reconstruction,19 but almost half the insurers who covered masculinizing surgery would not cover nipple reconstruction or revision procedures. This high level of denials is in keeping with anecdotal experience and suggests that insurance exclusions may act as a barrier to accessing transition-related care. These findings are valuable to physicians and patients alike, to aid in advocacy for treatment.

Despite the recent cultural and legislative shift that has resulted in widespread acknowledgement of the medical necessity of gender-affirming surgery to treat gender dysphoria,1,10,11 restrictive policies remain in place within some insurance companies. One explanation for the lack of coverage may be the paucity of supporting literature concerning psychological outcome of transgender patients following chest/breast reconstruction surgery. The Centers for Medicare and Medicaid Services has not issued a national coverage determination on gender reassignment surgery for Medicare beneficiaries because they deemed the clinical evidence to be inconclusive and stated that robust studies are needed.20 However, the lack of insurance coverage limits access to gender-affirming top surgery, which unsurprisingly leads to a paucity of clinical evidence. This is then cited as a reason to deny coverage of the procedure, and thus a deadlock is encountered. Another possibility for the limited insurance coverage may be related to perceived costs. Although initial costs are high, coverage refusal results in higher costs and poorer health outcomes because transgender individuals who cannot access health care have high unemployment rates and gross health disparities.7,21 Furthermore, health insurance coverage for the transgender population has been shown to be cost-effective12 and thus concerns are unwarranted.

We report a significantly higher proportion of favorable policies for masculinizing surgery, which corroborates with anecdotal experience that breast surgery is often denied in comparison to chest surgery. However, this finding is contrary to the experience reported by transpersons.7 Interestingly, this suggests that a gap exists between the coverage stated in policies and true coverage patterns. It is possible that the additional caveats in the policy medical necessity criteria, such as the need for hormone therapy, serve as a barrier to accessing treatment. Therefore, increased coverage for transmasculine top surgery in the form of more favorable policies does not equate to better treatment access in practice. The gender-based disparity in coverage rate may also be connected to the literature. More studies have shown improved quality of life and increased self-esteem following transmasculine chest surgery3–5 compared with transfeminine breast surgery, in which the literature is nearly void.6

WPATH standards of care are flexible guidelines based on expert consensus, which is similar to much of psychiatry.22 There is a deficit of high-level studies that support the medical necessity criteria in current use by insurers. This may account for the extensive variability in the requested criteria where no single criterion was universally used across insurance companies. However, the WPATH recommendations are widely available and standardized, creating structure in an evolving field.

Our findings revealed that insurance companies often list additional criteria that extended beyond WPATH recommendations for top gender-affirming surgery into “bottom” (genital reconstruction) surgery. One such criterion is the requirement for continuous living in a gender role congruent with their identity. Although WPATH reserves this criterion for genital reconstructive surgery or individuals younger than 18 years, more than half of the insurance policies requested evidence of such for top surgery, and some went further and doubled the recommended time from 1 to 2 years. This may be problematic because top surgery is often the first procedure undertaken in transition and can greatly facilitate continuous living in a congruent gender role, which is needed for bottom surgery.2 Furthermore, this criterion is based solely on expert consensus without supporting research. Thus, the use of this criterion for top surgery may present an unnecessary hurdle. It is possible that in the absence of high-level evidence to support WPATH guidelines, insurers choose to increase the rigor of which medical necessity is assessed to maximize the chances of identifying the candidates in most need. However, the increased stringency in medical necessity criteria not only places undue pressure on patients, it places third-party payers and health care providers at an impasse wherein large-cohort studies to assess the relevance of these additional criteria cannot be performed because of the limits placed by insurance exclusions.

Other supplementary criteria distinct from WPATH recommendations for breast/chest surgery were the requirement for hormone therapy and two referral letters. Hormone therapy may be indicated before breast surgery to maximize breast growth and obtain better surgical results. In certain cases, it may eliminate the need for surgery. Thus, its presence as a criterion in feminizing top surgery is justifiable. However, the indication for hormonal therapy is less clear in transmen and nonbinary individuals seeking masculinizing top surgery. In these patients, the physical changes linked to hormonal therapy may be unwanted and can prove more dramatic than surgery.23 There is no single path to transition, and treatment goals are individualized. Some patients may wish for only top surgery without the additional secondary sexual characteristics that arise with testosterone, such as hair loss. Thus, this compulsory use of hormone therapy to satisfy a surgical prerequisite may present a systemic barrier to care in addition to causing negative physical and psychological outcomes. Furthermore, the placement of arbitrary barriers by insurers, such as the requirement for an additional mental health professional referral, are not supported by a strong evidence base and can hinder health care access in a marginalized population. These restrictions can lead to catastrophic health consequences in the transgender population. Transgender persons have higher rates of substance abuse, depression, suicidal ideation, and suicide attempts compared with the nontransgender population.24–26 Gender affirmation has been noted as a key determinant of transgender health.24 Surgery is one treatment approach that can lead to gender affirmation and has been shown to attenuate mental health issues.27,28 Given the high rates of suicide and mental illness within this vulnerable population and the ameliorating effect of provision of transition-related care, insurance coverage reform is of paramount importance. By highlighting insurance exclusions and non–evidence-based barriers to care, we hope to impact these practices and extend access in this underserved patient population.

Conversely, other insurance policies lacked the requirements recommended by WPATH, such as established mental health professional credentials and a specific referral letter format. This deviation may be explained by the lack of transparency and clear definition of medical necessity in insurance policies as previously reported by other studies.14 It also may be explained by the nascent nature of transgender health care, which is still unfamiliar to many health care providers.7 Thus, there is a need for high-quality studies assessing the evidence behind each criterion to establish more definitive clinical guidelines.

This article is limited because of the wide variety in medical plans and the possible ongoing changes in company policies. Case-by-case policy was assumed to provide coverage; therefore, insurance coverage may be overestimated within this study. In addition, the theoretical coverage ascertained by written policies may not reflect the true insurance coverage practices. A future avenue of study will be to compare insurance policies with actual coverage practices. However, our study is strengthened by the large number and popularity of the insurance companies assessed. We hope to encourage greater uniformity between insurance companies with regard to their policy criteria, in addition to empowering both patients and surgeons with the information to enable them to advocate for treatment in this underserved population. Further studies should evaluate the efficacy of the medical necessity criteria used by both WPATH and insurance companies.

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CONCLUSIONS

Great variability exists in insurance coverage of gender-affirming “top” surgery, with more policies covering mastectomy as a health benefit than breast augmentation. Policy criteria vary greatly between insurance companies and often deviate from WPATH standards of care. More and higher quality studies are needed to provide an evidence basis for the criteria recommended. Increased clarity and transparency for medical necessity criteria are needed to allow patients and surgeons to educate and advocate for treatment.

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