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.
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.
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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