Navigating Insurance Policies in the United States for Gender-affirming Surgery

Abstract

Background: Patients with gender dysphoria seeking to undergo gender affirmation surgery are often challenged by lack of insurance coverage. The authors aim to review gender affirmation surgery policies and to highlight discrepancies between qualifying criteria across top insurance companies in the United States. Methods: The top 3 insurance companies in each state within the United States were determined by market share. Each insurance policy was analyzed according to coverage for specific “top surgeries” and “bottom surgeries.” Policies were obtained from company-published data and phone calls placed to the insurance provider. Results: Of the total 150 insurance companies identified, policies related to gender- affirming surgery were found for 124. Coverage for gender-affirming surgery varies by insurance company, state, and procedure. Most insurance companies, 122 of 124 (98%), covered chest masculinization, but only 25 of 124 (20%) of insurance companies covered nipple-areola complex reconstruction. Additionally, 36 of 124 (29%) insurance companies covered chest feminization. Vaginoplasty is covered by 120 of 124 (97%) insurance companies. Despite high rates of vaginoplasty coverage, vulvoplasty is only covered by 26 of 124 (21%) insurance companies. Phalloplasty and metoidioplasty are covered by 118 of 124 (95%) and 115 of 124 (93%) of insurance companies, respectively. Slightly more than half, 75 of 124 (60%) insurance companies covered penile prosthesis. Conclusions: As gender-affirming surgery insurance coverage increases, the policies regarding them remain inconsistent. Standardized policies across insurance companies would further increase access to gender-affirming surgery.