While the Insurance Gender Nondiscrimination Act (IGNA), also known as AB 1586, prohibits health plans from denying medically necessary health care to transgender individuals, the exact treatment options covered for individuals with gender dysphoria remain unclear in California. The determination of whether a health plan will cover a certain medical procedure to facilitate the transition to the opposite and identified sex of the health plan member hinges on the medical necessity of the procedure.
No established transgender procedure criteria
As opposed to the UK’s National Health Service (NHS), no governing body in the U.S. has explicitly delineated medically necessary treatments for gender dysphoria. This leaves a very big gray area for health insurance companies to deny medical procedures on the grounds that they are cosmetic and medically unnecessary for the health and well being of the transgender person. In a California Department of Managed Health Care Independent Medical Review (IMR) case upholding a health plan’s decision not to cover mammaplasty and mastectomy for a woman transitioning to a man, the medical review noted –
Further, a task force from the American Psychiatric Association (APA) has not provided definitive support for specific surgical treatment in patients with GID. The APA noted that, “[T]here is a critical need for an APA Position Statement on the Treatment of GID, and given the time it will take to develop treatment recommendations, a position statement should precede the development of recommendations”.
The lack of specific treatment guidelines and supporting documentation for the procedure led the Independent Medical Review to deny the procedure –
All told, the requested bilateral reduction mammaplasty, bilateral mastectomy, and bilateral nipple/areola reconstruction, have not been demonstrated to be medically necessary for treatment of this patient’s medical condition. -IMR Case MN12-14573
National Health Service has transgender dialed in
With respect to outlining necessary surgical procedures to address gender dysphoria and successfully help transgender individuals’ transition to the sex they identify with, NHS has very specific recommendations. The first step the NHS requires is a real life experience. (See: NHS Gender Dysphoria Treatment)
Real life experience living as identified
If you want to have gender confirmation surgery, you will first need to live in your preferred gender identity full time for at least a year. This is known as real life experience (RLE) and will help confirm that permanent surgery is the right decision.
Once your hormone treatment is under way, you can start as soon as you are ready with the support of your clinic. The length of RLE varies from person to person, but is usually between one and two years.
After the the transgender individual has lived as the preferred gender for period of time in the UK, they consult with their team of health care professionals which might include psychologists and primary care physicians about gender confirmation surgery.
Gender confirmation surgery
Once you have completed your RLE and you and your multi-disciplinary team (MDT) feels that you are ready, you may decide to have surgery to permanently alter your sex.
Trans man surgery may involve:
- a hysterectomy (removal of the womb)
- a salpingo-oophorectomy (removal of the fallopian tubes and ovaries)+
- construction of a penis using a phalloplasty or a metoidioplasty
Trans woman surgery may involve:
- an orchidectomy (removal of the testes)
- a penectomy (removal of the penis)
- construction of a vagina from the leftover tissue of the penis (known as a vaginoplasty)
Why is the U.S. so far behind?
I thought for sure that the country with the best health care in the world, so I’ve been told, would certainly have specific treatment options that health plans must offer for transgender people. To find out what those options were I sent an email to the Department of Managed Health Care which regulates most of the new individual and family health plans with a simple question.
Have you issued any guidelines for what health plans must include for the transgender health benefits?
Their most courteous reply was thus.
Thank you for contacting the California Department of Managed Health Care (DMHC). The DMHC licenses and regulates HMOs and other health plans in California. The DMHC does not license medical groups or facilities.
The Gender Nondiscrimination Requirements does not include a list of specific treatments/procedures that must be covered, it reminds plans that they cannot limit benefits due to an enrollee’s sex.
You can read the letter at our website- http://www.dmhc.ca.gov/library/reports/news/dl12k.pdf
If an enrollee believes their plan is limiting their coverage due to their sex, their first step is to file a grievance with their health plan regarding the issue. The enrollee can initiate this process by contacting the plan’s member service department and telling them they want to file a “formal grievance.” The plan will have 30 days to respond to the issue. The enrollee can file a complaint with the DMHC if the plan does not respond within 30 days or if they are not satisfied with their response. The consumer complaint packet can be obtained online at
This form can be submitted online or printed out and mailed or faxed.
Please let us know if you have any other questions.
Transgender individuals are trail blazers in California
So it would seem that the DMHC and the California Department of Insurance want people suffering from gender dysphoria to blaze the trail of treatment options with formal grievances. This trail blazing will be a combination of reliance on the IGNA and well documented physician statements supporting the medical necessity of a number of medical procedures that many health insurance companies will conclude are cosmetic and not covered by the health plan.
Building the transgender standard one grievance at a time
The formal grievance process puts the denial of transgender health services into the Independent Medical Review system of the DMHC. I was only able to find four decisions from the IMR regarding transgender services. Two decision made in 2013 overturned the denial of health care services by the health plan and two older decision from 2012 and 2009 upheld the denial of medical procedures. The most recent decisions seem to indicate that when the grievance is properly documented with sound reasoning for the medical necessity of the procedure, the IMR will make the health plan cover the surgery. The decisions can read at the end of the post.
Anthem Blue Transgender FAQ
Anthem Blue Cross got ahead of the curve by publishing a frequently ask questions guide to transgender health benefits. They probably sensed that there would be numerous questions so it was easier to develop an outline of benefits as opposed to reviewing each case like the other insurance carriers have opted to do. However, some folks have contacted me and said some of their requested surgeries have been denied by Anthem. It is difficult to know all the circumstances surrounding the denial because it might be a grandfathered health plan, self-funded health plan or one originating outside of California, and none of those have to follow the IGNA. See the FAQ at end of post.
Miles to go before we rest
What is certain is that accessing health benefits for a transgender person or an individual transitioning to their preferred gender is getting easier in California with the IGNA. But there are still miles to travel before people with gender dysphoria can be easily treated and supported in their transition. Whereas the UK already has established criteria for gender reassignment surgeries, transgender individuals in California will have to fight to get their health plans to cover medically necessary surgeries one case at a time.
Independent Medical Review Decisions
The transgender and gender dysphoria cases can be accessed at the DMHC IMR search site.
Reference ID numbers begin with either MN or EI. MN is the acronym for medical necessity and applies to cases in which the disputed treatment was either delayed, denied or modified by the HMO based on medical necessity.
Denial of mastectomy: overturned
- Case MN13-15051
- Medical Necessity
- 26 year old Male, General Surgery/Breast Surgery
A 26-year-old enrollee has requested bilateral mastectomy with chest reconstruction for the enrollee’s transgender reassignment. Findings: The physician reviewer found that review of the submitted documentation indicates the patient has a body mass index (BMI) of approximately 35. Obesity with a BMI of 35 slightly increases the risk of surgical complications. An individual with a BMI of 35 may be at higher risk for surgical and wound healing problems. However, a BMI of 35 is not a contraindication to proceeding with the requested surgery. The patient is an appropriate candidate for bilateral mastectomy with chest reconstruction from a medical standpoint. Psychological clearance for the proposed surgery should be obtained before the procedure is performed.
Denial of phalloplasty: overturned
- Case MN13-15055
- Medical Necessity
- 57 year old male, Reconstructive Surgery
A 57-year-old male enrollee has requested sexual reassignment surgery: free flap phalloplasty for treatment of his gender dysphoria. Findings: The physician reviewer found that the submitted documentation establishes the medical necessity of the requested procedure. Free flap phalloplasty is the preferred method for female-to-male genitalia reconstruction. This procedure is preferred to the pedicled groin flap. Neither of these techniques are single stage procedures. Multiple procedures are common for both, but there are usually fewer procedures required when using the free flap compared to the pedicled groin flap. The free flap procedure is better vascularized, has fewer complications and has better outcomes compared to the pedicled groin flap. Moreover, the free flap procedure meets all of the criteria sought by the patient. The free flap does not contain muscle and generally does not affect forearm or hand strength. Urinary problems are common long-term for both procedures and urology involvement and follow up is necessary. A penile prosthesis is necessary for intercourse in any free flap surgery except for the fibula free flap. The anterior lateral thigh flap and latissimus musculocutaneous flaps are less preferred than the free flap because they are usually much thicker tissues and are too large. All told, the requested free flap surgery is a well-accepted procedure and is medically appropriate and necessary for this patient.
Denial of mammaplasty and mastectomy: upheld
- Case MN12-14572
- Medical Necessity
- 27 year old male, Reconstructive Surgery
A 27-year-old male has requested bilateral reduction mammaplasty, bilateral mastectomy, and bilateral nipple/areola reconstruction for treatment of his persistent gender dysphoria. Findings: The physician reviewer found that based on review of the available records, the patient has documented gender identity disorder (GID) and has requested coverage for removal of both breasts. A letter from one provider states that the patient has a history of gender dysphoria and that the patient’s condition would likely improve with surgery. The documentation from the plastic surgeon only states that the patient has a diagnosis of trans-sexualism and that the patient would like to have both breasts removed. The American Society of Plastic Surgeons (ASPS) defines cosmetic surgery as a procedure being performed “to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem”. By contrast, the ASPS consider reconstructive surgery to be performed on “abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease”. Although the procedure is generally performed to improve function, it may also be done to approximate a normal appearance. Thus, there may be an indication for breast reduction or mastectomy if a reconstructive goal is adequately defined. However, this patient’s records do not establish an indication for a reconstructive medical procedure. Specifically, the provider does not provide adequate reasoning for reconstruction and only states that the patient requests breast removal for a diagnosis of trans-sexualism. The provider does not detail the patient’s functional problem and degree of severity. The patient’s social worker states the requested services will improve the patient’s comfort within his own body, but this documentation does not provide adequate support to establish the services as medically necessary (emphasis added). Further, a task force from the American Psychiatric Association (APA) has not provided definitive support for specific surgical treatment in patients with GID. The APA noted that, “[T]here is a critical need for an APA Position Statement on the Treatment of GID, and given the time it will take to develop treatment recommendations, a position statement should precede the development of recommendations”. All told, the requested bilateral reduction mammaplasty, bilateral mastectomy, and bilateral nipple/areola reconstruction, have not been demonstrated to be medically necessary for treatment of this patient’s medical condition.
Denial of mastectomy: upheld
- Case MN09-10353
- Medical Necessity
- 20 year old female, Reconstructive Surgery
A 20-year-old female enrollee has requested gender reassignment chest surgery (bilateral mastectomy) for the treatment of her gender disorder of adulthood. Findings: The physician reviewer found that the Harry Benjamin International Gender Dysphoria Association’s (HBIGDA) Standards of Care for Gender Identity Disorders represent the generally accepted standard of care in this setting and are applicable in this case. This patient meets HBIGDA diagnostic criteria for gender identity disorder based on the following: • the patient has a desires to live and be accepted as a member of the opposite sex accompanied by a wish to make the body congruent with this desire; • the patient’s desire has been present for at least two years; and • the patient’s disorder is not a symptom of another mental disorder or chromosomal abnormality. Before beginning hormone therapy or performing breast surgery, HBIGDA criteria requires a letter from a mental health professional indicating the following: 1. the patient’s general identifying characteristics; 2. the initial and evolving gender, sexual and other psychiatric diagnoses; 3. the duration of their professional relationship including the type of psychotherapy or evaluation that the patient underwent; 4. eligibility criteria that have been met and the mental health professional’s rationale for hormone therapy or surgery; 5. the degree to which the patient has followed the HBIGDA Standards of Care to date and the likelihood of future compliance; 6. whether the author of the letter is part of a gender team; and 7. a statement that the sender of the letter welcomes a phone call to verify the fact that the mental health professional actually wrote the letter. Psychotherapy is not an absolute requirement for treatment and there is no specific number of required sessions before treatment. However, breast surgery produces relatively irreversible changes to the body. This is usually the first surgery performed by female to male transgender patients. For some patients (as may be the case with this patient), it is the only surgery they undertake. It is not necessary that the patient take hormones prior to this surgery. However, before performing the requested surgery, steps must be taken to ensure the patient’s well being. In this case, there is an absence of a letter from a mental health professional/therapist which details his or her involvement with this patient over an extended period of time and which adequately addresses all of the points mentioned above. (emphasis added).Thus, based upon the documentation provided at this time, the medical necessity of the proposed procedure has not been established.
Transgender Success Story
A client recently reported that his Anthem health plan did authorize some surgical procedures for his transition. Of the two requested surgeries, one was considered medically necessary and the other was deemed cosmetic. Here are a few of his tips to navigating the insurance maze to get transgender health benefits for transition covered.
- Ask a lot of questions since there is much confusion surrounding trans benefits and it’s hard to immediately tell what is covered or not.
- Seek professional help from specialists like Kevin Knauss who will go out of his way to help you navigate this insurance maze.
- Tell your doctors in California that even where there is no explicit trans benefit, many procedures will be covered with prior authorization if deemed medically necessary so have strong letters from your therapists, doctors and endocrinologist stating that your procedures are “medically necessary” so that they can get covered.
- Be aware that your surgeon and their insurance department are likely as confused as you are about the new trans law so you have to educate yourself and them as well.
- Anthem seems to be the most trans aware insurance at present in Cali as many people have been able to get procedures covered with them so fight your insurance companies, file appeals where necessary but also be willing to change to progressive insurance like anthem if necessary.
See Also: Anthem Blue Cross Transgender FAQs