Health insurance coverage varies for gender-affirming top surgery in transgender patients

Reviewed by James Ives, M.Psych. (Editor)Oct 3 2019

Insurance companies having variable policies for covering gender-affirming breast/chest "top" surgery in transgender patients, according to a special topic paper in the October issue of Plastic and Reconstructive Surgery^®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Our survey study finds marked variation in policy criteria for top surgery between insurers. These criteria often deviate from established global recommendations, and some insurers categorically deny access to gender-affirming top surgery."

Yvonne Marsha Rasko, MD, lead author  from University of Maryland School of Medicine, Baltimore

Insurers have inconsistent criteria for covering transgender breast/chest surgery

Gender-affirming surgery refers to medically necessary reconstructive procedures performed to treat gender dysphoria, as outlined in the evidence-based standards of care developed by the World Professional Association for Transgender Health (WPATH). Often the first and sometimes only form of surgery undertaken by patients in transition is top surgery: bilateral mastectomy (masculinizing chest surgery) in transgender men and breast augmentation (feminizing chest surgery) in transgender women.

Both forms of top surgery improve quality of life and reduce symptoms of gender dysphoria in transgender individuals. With recent cultural shifts and legislative mandates, the medical necessity of these procedures is now widely acknowledged – yet many patients are still denied insurance coverage for transition-related reconstructive surgery.

Dr. Rasko and colleagues evaluated variability in insurance coverage and policy criteria for gender-affirming breast/chest surgery. The researchers analyzed coverage status from 57 US insurance companies, only one of which had no relevant policy on these procedures.

Fifty-three of the 57 insurance companies provided coverage for gender-affirming top surgery, after preauthorization. Two companies provided coverage on a case-by case basis; one provided no coverage. Only two insurers had criteria consistent with WPATH recommendations.

The survey revealed discrepancies in coverage for the two types of top surgery. While 96 percent of insurance companies covered bilateral mastectomy/masculinizing surgery in transgender men, only 68 percent covered breast augmentation/feminizing surgery in transgender women. "The insurers that did not provide coverage for transfeminine breast surgery listed the procedure as 'not medically necessary,'" the researchers write.

Nearly all had companies had general criteria for covering masculinizing chest surgery, but only about half had similar criteria for preapproval of feminizing breast surgery. Many insurers had additional criteria that were inconsistent with WPATH standards, such as time living in a congruent gender role, preceding hormone therapy, and evaluation by multiple mental health professionals.

"We have highlighted the great variability in coverage and medical necessity criteria for gender-affirming top surgery across insurance companies," Dr. Rasko and coauthors conclude. "We hope to encourage greater uniformity between insurance companies in 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."

In a video commentary on the Plastic and Reconstructive Surgery website, ASPS Member Surgeon Loren Schechter, MD, comments: "The authors highlight many of the challenges and inequities associated with insurance policies pertaining to medically necessary care in the transgender and gender-diverse community." Dr. Schechter adds, "Additional studies are required to bolster the preponderance of medical evidence supporting gender-affirming medical and surgical care."