Has anyone had success challenging insurance for transgender top surgery?

I have insurance through the healthcare marketplace. They are denying coverage for all trans related healthcare. Hormones, surgery, counseling, everything. Has anyone successfully challenged a denial like this? I am wondering if a surgeon could help me have my insurance cover my surgery despite them having a denial in the coverage.

Doctor Answers 4

Insurance Coverage and Transgender Top Surgery

It is important to gather all the cost information for Top Surgery from all of the surgeons you consult with. Additionally, you will also incur post-operative costs such as a medical compression vest, medications, paper tape, gauze, scar care and more.

There are a number of states that now prohibit discrimination and legally require #insurance companies to provide transgender health coverage. If you live in a state where surgery coverage is not mandated by law, you still might be able to get your top surgery covered via student health insurance. To get #Top Surgery covered by insurance there are a number of requirements. Here are some of the obstacles you may face:

1. Meeting the insurance company's basic criteria: legal adult status, Gender Dysphoria diagnosis, support letters from qualified mental health practitioners, your primary care provider and your surgeon. 

2. Having to pay out-of-pocket for surgery, then getting a reimbursement from the insurance company.

3. Having to be evaluated by a board of in-network doctors.

4. Finding in-network surgeons who have Top Surgery experience.

Keep in mind, that coverage varies between health insurance companies, states, and plans. Read your policy completely, not only the summary, and look for the #exclusions and limitations section. Finally, call your insurance company's member services department, or, contact a #benefits representative and ask the following:

• Is my selected surgeon a provider with my specific plan? (Make sure that you provide the representative with your surgeon's NPI number.)
• If my surgeon is NOT a provider, does my plan have out of network benefits?
• Does my plan cover gender confirmation Top Surgery?
• How much is my deductible?

Insurance Coverage and Transgender Top Surgery

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It is important to gather all the cost information for Top Surgery from all of the surgeons you consult with. Additionally, you will also incur post-operative costs such as a medical compression vest, medications, paper tape, gauze, scar care and more.

There are a number of states that now prohibit discrimination and legally require #insurance companies to provide transgender health coverage. If you live in a state where surgery coverage is not mandated by law, you still might be able to get your top surgery covered via student health insurance. To get #Top Surgery covered by insurance there are a number of requirements. Here are some of the obstacles you may face:

1. Meeting the insurance company's basic criteria: legal adult status, Gender Dysphoria diagnosis, support letters from qualified mental health practitioners, your primary care provider and your surgeon. 

2. Having to pay out-of-pocket for surgery, then getting a reimbursement from the insurance company.

3. Having to be evaluated by a board of in-network doctors.

4. Finding in-network surgeons who have Top Surgery experience.

Keep in mind, that coverage varies between health insurance companies, states, and plans. Read your policy completely, not only the summary, and look for the #exclusions and limitations section. Finally, call your insurance company's member services department, or, contact a #benefits representative and ask the following:

• Is my selected surgeon a provider with my specific plan? (Make sure that you provide the representative with your surgeon's NPI number.)
• If my surgeon is NOT a provider, does my plan have out of network benefits?
• Does my plan cover gender confirmation Top Surgery?
• How much is my deductible?

Insurance for top surgery

This is a very frustrating situation.  Sometimes the denial can be overturned by a letter of appeal from either your primary care physician or the plastic surgeon who is planning on performing the top surgery. 

Insurance for top surgery

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This is a very frustrating situation.  Sometimes the denial can be overturned by a letter of appeal from either your primary care physician or the plastic surgeon who is planning on performing the top surgery. 

Problems with insurance coverage

There are many problems with insurance coverage of transgender surgery, even when the policy specifically states that the procedure is covered. We have become very frustrated with the insurance companies callous approach to this situation. Be sure to get everything in writing and prepare for stormy seas.

Problems with insurance coverage

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There are many problems with insurance coverage of transgender surgery, even when the policy specifically states that the procedure is covered. We have become very frustrated with the insurance companies callous approach to this situation. Be sure to get everything in writing and prepare for stormy seas.

FTM surgery covered by insurance

I'm sorry you're having a hard time getting the services you need for your transition. Unfortunately, many insurance companies have specific exclusions written into their policies. Depending on the type of insurance plan, they may be well within their rights to deny certain procedures. That being said, many times denials can be overturned if an appeal is made by the healthcare professional. Specific to trans surgery however, any reputable board-certified plastic surgeon performing FTM breast surgery will require a letter from the therapist showing appropriate counseling and gender identity disorder diagnosis prior to performing surgery  Although I do not know your particular details, you may be best served by beginning with your primary care physician or therapist to see if an appeal can be made. Best of luck.

FTM surgery covered by insurance

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I'm sorry you're having a hard time getting the services you need for your transition. Unfortunately, many insurance companies have specific exclusions written into their policies. Depending on the type of insurance plan, they may be well within their rights to deny certain procedures. That being said, many times denials can be overturned if an appeal is made by the healthcare professional. Specific to trans surgery however, any reputable board-certified plastic surgeon performing FTM breast surgery will require a letter from the therapist showing appropriate counseling and gender identity disorder diagnosis prior to performing surgery  Although I do not know your particular details, you may be best served by beginning with your primary care physician or therapist to see if an appeal can be made. Best of luck.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.