What To Do About GAS Coverage: Concordance of National Insurance Criteria with WPATH Standards of Care for Gender-Affirming Surgery
Sarah Diaddigo*, Myles N. LaValley, Paul A. Asadourian, Grant Feuer, Paige Warner, Christine Rohde
Division of Plastic and Reconstructive Surgery, Columbia University Irving Medical Center, New York, NY
Given that gender-affirming surgery (GAS) is considered medically necessary for some transgender and non-binary (TGNB) individuals, the aim of this study is to assess the concordance of insurance criteria for GAS with the most recent World Professional Association for Transgender Health (WPATH) Standards of Care (SOC).
Insurance policies for coverage of gender-affirming genital ("bottom surgery"), chest ("top surgery"), and facial reconstruction from companies representing 80% of the market coverage in each state were evaluated. The policies were classified into three categories: no-coverage (NC), case-by-case (CC), and preauthorization (PA). Among PA policies, specific surgeries offered and their criteria for coverage were analyzed for adherence to the WPATH SOC.
Bottom surgery policies were most concordant for age and gender dysphoria criteria, and masculinizing top surgery policies were most concordant for hormone therapy and referral criteria. Feminizing top surgery criteria were more restrictive than for masculinizing. For all types of surgery, duration of continuous living in a congruent gender role was the most discordant criterion, being more restrictive than WPATH guidelines in over 98% of insurance policies. Even when GAS was preauthorized, many policies lacked coverage of specific procedures and related treatments. Facial GAS exclusion was attributable to a lack of explicit criteria, rather than overt misalignment, and surgeries with cosmetic overlap such as necklifts, lip enhancements, hair transplants, and facelifts were the least frequently covered. Additionally, reversal and revisionary surgery were covered in less than 25% of policies for each type of GAS.
Compared to previous literature, insurance coverage and criteria are becoming more concordant with medical guidelines but still fail to capture the nuances of gender-affirming care. Furthermore, concordance varies across categories of surgery, which reflects both socio-political influence on medical necessity, as well as an additional burden of proof for treatments with elective cosmetic overlap.
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