Navigating Insurance

Navigating insurance for top surgery can be a challenge. Insurance plans often require that teens meet certain prerequisites prior to top surgery. We’re here to walk you through the process, coordinate care with your insurance provider, and answer any questions you may have.

The process

To get started, we will set up a surgical consultation appointment. We’ll review your insurance coverage and discuss what is required for authorization. Most likely, your insurance company will require a full physical exam along with two approval letters. Once all required paperwork is completed, we will submit it for authorization to your insurance company and keep you informed of the status of your application.     

Don’t get discouraged by an initial denial. More often than not, appeals are necessary before surgery is approved by insurance providers. We’ll partner with you in submitting an appeal letter and take action to optimize the approval process. Once the surgery is authorized, the surgery date will be confirmed. If you have any questions along the way, please don’t hesitate to ask. We’re dedicated to doing whatever we can to obtain approval. 

Tips for success

  • Investigate your insurance plan and read the fine print on what is covered and what’s not covered. Ask what stipulations there are with “top surgery” or “gender reassignment surgery,” and inquire about the appeal process—how often requests are appealed and how often they eventually lead to approval. If the insurer says there is no coverage, you’ll have time to explore other plans.
  • Look for key language regarding age. If your insurance policy specifically states that a person must be 18 years old for coverage, then we must wait until the patient is that age. If your policy does not specify an age, occasionally we have success by appealing with letters of support for teens under the age of 18.
  • Keep in mind that procedures deemed medically appropriate are covered, while cosmetic procedures are not. For example, top surgery can be proven as medically appropriate. Liposuction cannot.
  • Make sure that approval letters are in place. Most insurance plans require approval letters: (1) a letter (or two) from a professional mental health provider attesting to gender dysphoria (a conflict between assigned sex at birth and gender identity), and sometimes (2) a letter from a doctor stating that 12 months of hormone therapy has been completed (this can vary by plan).