Plans often deviate from recommended criteria for coverage; some insurers categorically deny access
THURSDAY, Oct. 17, 2019 (HealthDay News) — There is great variability in coverage and medical necessity criteria for gender-affirming top surgery across insurance companies, according to a study published in the October issue of Plastic and Reconstructive Surgery.
Ledibabari M. Ngaage, M.B., B.Chir., from the University of Maryland in Baltimore, and colleagues assessed insurance coverage of “top” gender-affirming surgery and evaluated the differences between insurance policy criteria and World Professional Association for Transgender Health (WPATH) recommendations. Policies were determined using internet-based information and telephone interviews.
Based on the 57 insurers reviewed, the researchers found that bilateral mastectomy (transmasculine) was covered by significantly more insurers than breast augmentation (transfeminine; 96 versus 68 percent). WPATH-consistent criteria were used by only 4 percent of insurers, with no criterion universally required by insurers. Beyond WPATH guidelines, additional prerequisites for top surgery coverage were continuous living in congruent gender role, two referring mental health professionals, and hormone therapy before surgery. A significantly higher proportion of transfeminine policies required hormone therapy versus transmasculine policies (90 versus 21 percent).
“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,” the authors write.
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