Health Insurance Coverage of Gender-Affirming Top Surgery in the United States

Ledibabari M. Ngaage, M.A.Cantab., M.B., B.Chir.; Brooks J. Knighton, B.S.; Katie L. McGlone, B.S.; Caroline A. Benzel, B.S.; Erin M. Rada, M.D.; Rachel Bluebond-Langner, M.D.; Yvonne M. Rasko, M.D.


Plast Reconstr Surg. 2019;144(4):824-833. 

In This Article

Abstract and Introduction


Background: Despite the medical necessity, legislative mandates, and economic benefits of gender-affirming surgery, access to treatment remains limited. The World Professional Association for Transgender Health (WPATH) has proposed guidelines for transition-related surgery in conjunction with criteria to delineate medical necessity. The authors assessed insurance coverage of "top" gender-affirming surgery and evaluated the differences between insurance policy criteria and WPATH recommendations.

Methods: The authors conducted a cross-sectional analysis of insurance policies for coverage of top gender-affirming surgery. Insurance companies were selected based on their state enrollment data and market share. A Web-based search and individual telephone interviews were conducted to identify the policy. Medical necessity criteria were abstracted from publicly available policies.

Results: Of the 57 insurers evaluated, bilateral mastectomy (transmasculine) was covered by significantly more insurers than breast augmentation (transfeminine) (96 percent versus 68 percent; p < 0.0001). Only 4 percent of companies used WPATH-consistent criteria. No criterion was universally required by insurers. Additional prerequisites for coverage that extended beyond WPATH guidelines for top surgery were continuous living in congruent gender role, two referring mental health professionals, and hormone therapy before surgery. Hormone therapy was required in a significantly higher proportion of transfeminine policies compared with transmasculine policies (90 percent versus 21 percent; p < 0.0001).

Conclusions: In addition to the marked intercompany variation in criteria for insurance coverage that often deviated from WPATH recommendations, there are health care insurers who categorically deny access to top gender-affirming surgery. A greater evidence base is needed to provide further support for the medical necessity criteria in current use.


Gender-affirming surgery is a medically necessary procedure to treat gender dysphoria.[1] It is not a single procedure, but a complex team process involving multiple medical, mental health, and surgical specialities working in tandem. The reconstructive operations involved in gender affirmation, alongside medical necessity criteria, are outlined in the standards of care by the World Professional Association for Transgender Health (WPATH) (Table 1).[1] Often, the first (and at times, the only) operation that patients undergo in transition is "top" surgery. This refers to bilateral mastectomy (masculinizing chest surgery), performed in transmen and nonbinary individuals, and breast augmentation (feminizing breast surgery), performed in transwomen and nonbinary individuals.[2] These procedures have been shown to improve quality of life and reduce symptoms of gender dysphoria in transgender individuals.[3–6]

The greatest barrier to accessing health care treatment, as reported by the transgender population, is cost.[7] Therefore, there is increased reliance on insurance companies to facilitate access to treatment. Legislation placed in 2014[8,9] has prohibited transgender-specific exclusions in health care insurance coverage. This legal shift, in addition to the growing consensus regarding the medical necessity of gender-affirming procedures,[1,10,11] may account for the 155 percent rise in gender-confirmation surgery.[12] However, this statistic is reported by a survey and thus likely represents a conservative estimate of the true increase. Furthermore, coverage of transition-related surgery is supported by evidence that demonstrates the cost-effectiveness of such policies.[13]

Nonetheless, a survey[7] noted that more than half (55 percent) of respondents who sought coverage of gender-affirming surgery were denied. In addition, rates of transition-related coverage differed by gender. The same study reported that transmasculine individuals were more likely to report being denied insurance coverage of surgery compared to their transfeminine counterparts. However, this survey is limited, as it does not report the proportion that met the medical necessity standard for preauthorization of these operations. Insurance policies often show variability in coverage, do not have standardized criteria, and do not conform to accepted medical guidelines.[14,15] This can result in difficulty interpreting and meeting the medical necessity benchmark. Although the WPATH standards of care are flexible, they offer guidance and standardized criteria for medical necessity. Currently, the literature is void on insurance policy criteria for top gender-affirming surgery and/or how they relate to WPATH standards of care.

This study aims to evaluate the variability in insurance coverage and policy criteria for gender-affirming breast/chest surgery, and assess gender-related disparity in health care coverage. Furthermore, we aim to bring clarity to coverage practices so both surgeons and patients may be better informed to advocate for treatment.