How To Get Top Surgery Covered By Insurance?

The tide is turning in the United States, with more insurance companies recognising the medical necessity of gender-affirming procedures and funding Top Surgery.

The American Medical Association (pdf), American Psychiatric Association (pdf), and World Professional Organization for Transgender Health (pdf), as well as insurance companies like Aetna, have all endorsed gender-affirming procedures as medically necessary.

State Non-Discrimination Laws

A number of states have passed laws prohibiting discrimination and requiring insurance companies to cover transgender people. Oregon, California, Colorado, Vermont, Connecticut, Massachusetts, Washington, Illinois, New York, Nevada, Delaware, Pennsylvania, Michigan, Minnesota, Montana, Rhode Island, and Washington, D.C. are some of these states.

Even if your state does not require surgery coverage, you may be able to get your top surgery covered through student health insurance.

Am I Covered?

Health insurance providers, states, and plans all have different levels of coverage. Don’t assume that one company, state, or plan has the same degree of coverage as another. Look for the section on exclusions and restrictions in your insurance, not just the summary. Next, contact the member services department of your insurance provider, or a benefits representative at your place of employment, and ask:

  • Is the surgeon I’ve chosen a provider for my particular plan? (Give your surgeon’s NPI number to the representative.)

How to Find Insurance

There are a few conditions that must be met in order for Top Surgery to be approved by insurance. You may have to jump through some hoops, such as:

  • Legal adult status, Gender Dysphoria diagnosis, support letters from qualified mental health practitioners, your primary care physician, and your surgeon must all meet the insurance company’s basic standards.
  • Paying for surgery out of pocket and then receiving payment from the insurance company.

If your insurance company refuses to pay for your Top Surgery, you have every right — and should — to challenge the decision.

The Affordable Care Act and the Patient’s Bill of Rights establish several significant protections for transgender people in health insurance:

  • Coverage denials are no longer an issue: everyone, regardless of gender, can apply for health insurance and obtain the care they require. (Take, for example, a trans man’s hysterectomy.)
  • Acceptance of pre-existing conditions: Insurers can no longer refuse coverage to a person who has what they consider a pre-existing condition, which includes being transgender.
  • Plan cancellations are no longer permitted: Health insurers used to be able to discontinue coverage when a person’s health needs changed, such as when they came out as transgender.
  • WPATH Clarifies Medical Treatment Needs, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Around the World

Does insurance cover top surgery?

The tide is turning in the United States, with more insurance companies recognising the medical necessity of gender-affirming procedures and funding Top Surgery.

Non-binary people who are paying for Top Surgery out of pocket don’t need a letter of medical necessity and can proceed with a surgeon who employs the informed consent paradigm. A letter of medical necessity from a certified mental health expert is required if the surgeon does not employ informed consent.

Non-binary people who want to use insurance to pay for Top Surgery may confront additional challenges. Transgender insurance policies frequently require the patient to identify as a binary gender. In this scenario, the therapist who is writing the needed statement of medical necessity should be aware of how to draft the letter in a way that satisfies insurance standards, such as utilizing he/him pronouns. If a binary identification is not necessary, the letter should state how long the person has lived as a non-binary person and used their current name. Typically, insurance companies want trans patients to follow a typical transition formula that focuses on specified treatments carried out in a specific order, effectively excluding individuals who don’t follow the standard. The truth is that you don’t have to be on hormones or live as a specific gender to be covered for Top Surgery in some situations and with certain insurance companies.

The FTM Top Surgery Insurance Coverage Guide In the United States walks you through the process of obtaining insurance coverage for TopSurgery, and it’s worth noting that it was written by a non-binary person who is not on Testosterone, lives in a state with no legal protections at the time, and has an insurance plan with exclusions—yet they were still able to have their Top Surgery covered! This step-by-step instruction, written in plain English, will show you how to:

Can I be denied top surgery?

Gender-affirming surgery operations are medically essential reconstructive procedures for the treatment of gender dysphoria. Top Surgery is the most common gender-affirming surgery for trans masculine people, and research demonstrates that it improves quality of life and reduces gender dysphoria symptoms.

Despite the fact that Top Surgery is now widely recognized as a medical necessity, insurance companies continue to deny payment for the treatment.

Insurance companies need proof of medical necessity for Top Surgery, but friends, family, and loved ones frequently ask trans and non-binary people to prove why they need surgery. If you’re asked to explain why Top Surgery is medically required for you, this review of evidence-based science confirming Top Surgery’s effectiveness can be a beneficial addition to your defense arsenal.

How much does top surgery cost FTM?

The cost of cosmetic surgery varies significantly based on your insurance coverage, where you reside, and which surgeon you choose.

Currently, the typical cost of FTM and FTN top surgery is between $3,000 and $10,000.

The average cost of MTF and MTN top surgery varies significantly according on body size, body shape, and desired breast size. The cost of this procedure often ranges between $5,000 and $10,000. A hospital or facility fee, as well as an anesthesiologist cost, are usually added to the overall payment.

Can you get top surgery without taking testosterone?

Take the time to perform some in-depth research on the internet. Reading blogs, viewing YouTube videos, and looking at before and after images are all examples of this (especially from people with a similar body type to your own.) You’ll develop a good feel of which Surgeon is suitable for you as you read about Top Surgery treatments and Surgeons. There’s a lot to think about, including the operations they offer, their geographic location and wait list, your budget, and so on, so don’t make a hasty selection. Make a list of advantages and disadvantages, evaluate (and re-evaluate) your budget, and keep your options open as you learn more about the Surgeons who are accessible to you. You will not be dissatisfied with your choice of Surgeon if you make an informed and planned decision based on your needs. » Locate a Surgeon

Choosing a Procedure

The surgeon you meet with will give you their professional opinion on the best procedure for you based on your body type, chest size, and skin elasticity, as well as your Top Surgery goals, which may include a low revision rate, minimal scarring, preferences for nipple and areolar size and placement, sensation, and other factors. See also: The Easiest Way to Determine Which FTM Top Surgery Procedure Is Best For You

In Double Incision Top Surgery, “dog ears” refers to excess skin and fat that “puckers” out at the major incision line as it goes around the side of the chest. The most common reason for a revision operation following Double Incision is “dog ears.” Finding out if your surgeon’s revision policy covers dog ear repair is a smart idea because revision surgery can cost almost as much as the original operation. A rising number of surgeons are able to avoid dog ears with Double Incision by performing extra liposuction below the arm pits on the sides of the chest. Staying close to your optimal weight before FTM Top Surgery might also help you avoid dog ears.

Eligibility & Requirements

Hormone therapy is not required for Top Surgery under the WPATH Standards of Care. (The exception is if you are attempting to obtain U.S. insurance coverage for Top Surgery, in which case the insurance company may need 1 year of HRT.) One advantage of taking T before surgery is that it can help you build larger chest muscles, giving the surgeon more contour to work with and potentially improving surgery results. This can, however, be accomplished with only push-ups and no testosterone.

Possibly. A letter from a mental health expert assessing your preparedness for surgery is often required by surgeons. For some guys, getting that letter can take months or years, depending on their access, resources, and, in certain situations, the therapist’s “gatekeeping.” Surgeons who follow the Informed Consent paradigm, on the other hand, will give services without a therapist’s letter. Here’s where you can learn more about Informed Consent.

The World Professional Association for Transgender Health publishes the Standards of Care (SOC) for the Health of Transsexual, Transgender, and GenderNonconforming People (WPATH). The SOC’s overarching purpose is to provide clinical guidance* to health professionals so that they can help transsexual, transgender, and gender nonconforming people achieve their full potential in terms of overall health, psychological well-being, and self-fulfillment. Primary care, gynecologic and urologic care, reproductive alternatives, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical therapies are all examples of services that may be provided. The SOC are based on the most up-to-date scientific evidence and professional consensus.

  • Be of legal age in the jurisdiction where surgery will be performed (and follow SOC regulations for children and adolescents*)
  • If there are any significant medical or mental health problems, they must be under reasonable control at the time of operation.

*Note that the WPATH criteria are guidelines only, not regulations or laws, and not all surgeons follow them.

Some surgeons need patients to be 18 years old or older to undergo surgery, while others will operate on children under the age of 18 with parental agreement. The following is taken from the WPATH SOC:

Chest surgery in FtM patients could be done sooner, preferably after a year of testosterone medication and enough time living in the chosen gender role. The goal of this suggested sequence is to give teenagers enough time to acclimate to a more masculine gender role and socialize before undergoing irreversible surgery. Depending on an adolescent’s clinical circumstances and gender identity expression goals, however, alternative treatments may be more appropriate.

Preparing for Top Surgery

Stop smoking if you do. (See the preceding paragraph.) Regularly exercise and eat a healthy, balanced diet. Increasing the muscle on your chest will give the surgeon more shape to work with, resulting in better aesthetic outcomes. Alcohol should be avoided for two weeks before surgery since it can cause excessive bleeding and bruising. Before surgery, your surgeon may ask you to stop taking testosterone for 2-4 weeks. If you’re taking any other medications, talk to your surgeon and possibly the anesthesiologist about them.

This is something you should definitely discuss with your surgeon because there are a variety of viewpoints on this. Surgeons advocate quitting T before and/or after surgery for two main reasons:

  • Testosterone levels have been linked to delayed wound healing in some studies.
  • Because testosterone causes blood to thicken, it raises the risk of deep vein thrombosis (blood clots.)

Both of these causes have been contested, and some research suggests that testosterone may aid in the avoidance of post-operative deep vein thrombosis and the alleviation of incisional discomfort. According to new research published in 2018, there is little evidence to justify the practice of discontinuing Testosterone before to Top Surgery.

If there’s a chance of better healing without T, it’s usually worth stopping—unless you’re one of those guys who loses a lot of energy and mood without it. In any case, consult your surgeon.

If you have a cold or the flu and your surgery date is nearing, your surgeon may decide to postpone your procedure. To discuss your symptoms and choices, contact your surgeon straight soon.

The time it takes to complete Top Surgery in the OR varies depending on the surgery and the surgeon. In general, a Double Incision procedure takes 2-4 hours, a Peri-Areolar procedure 3-4 hours, and a Keyhole procedure 1.5-3 hours.

Top Surgery Recovery and Post-op Care

The majority of Top Surgeries are performed as outpatient procedures, either in a hospital or a private “ambulatory” facility (facilities that offer same-day surgical care.) To put it another way, you’ll be able to return to your hotel the same day as your procedure. Only if there are underlying health concerns that need to be watched during the early recovery period, such as respiratory conditions, severe anesthetic reactions, or a history of blood clots, would an overnight stay be required.

If you’re coming from out of town for Top Surgery, you’ll need to stay in the area for 7-10 days for your Surgeon’s post-operative appointment(s).

Make sure to inquire about nearby hotel discounts with your surgeon.

It’s important to note that you must have a caretaker with you during this period. Many surgeons will arrange for a medical caregiver to accompany you overnight and/or on a daily basis. A friend or loved one can be your caregiver, but they must be experienced with wound care and offering physical—and frequently intimate—assistance.

The answer may be contingent on the procedure you’re having and the preferences of your surgeon. The role of post-operative compression in the healing process is critical. While wearing a binder after surgery can be uncomfortable, it helps to reduce bruising and swelling while also keeping the operative region firmly in place and supporting the desired chest contour. Your surgeon may or may not offer you with a binder (be sure to inquire.) A compression binder is often worn for 3-6 weeks after surgery. Follow your surgeon’s post-operative compression recommendations.

For post-operative compression, some surgeons recommend using an Ace bandage rather than a binder. Ace bandages, it’s said, are less expensive than a medical-grade compression binder.

Drains are likely to be used if you have a double incision or peri-areolar Top Surgery, depending on the operation you undergo and what your surgeon suggests. For up to a week after leaving the hospital or clinic, you will need to empty your drains at regular intervals throughout the day. Instruction is given by your surgeon or a nurse. Some surgeons do not utilize drains at all. Dr. Alan Dulin of Texas, for example, was a pioneer in the development of a Top Surgery technique that does not require drains. Also see: Are Post-Surgery Drains Really Necessary?

This varies greatly from person to person, but in general, the discomfort is mild to severe. For post-operative pain, many surgeons prescribe Percocet or Vicodin, however for many people, Tramadol or Tylenol suffice.

This is dependent on your surgeon’s techniques. Some surgeons use an absorbable subcuticular suture that dissolves naturally and does not need to be removed. Other surgeons will require you to return to their clinics a week after surgery to have non-absorbable sutures removed.

Your surgeon will provide you post-operative instructions on how to care for your wounds and clear your drains (if you have them.)

When it comes to employment, the answer is dependent on the type of job you have. If you work at a desk job, prepare to return in 1-2 weeks. It is suggested that you wait two weeks. It’s recommended that you take 4-6 weeks off after surgery if you have a more active profession that requires lifting and other physically demanding tasks. Students should take 1-2 weeks off from school and 4-6 weeks off from athletics.

Only a few days after surgery, light activity such as walking is recommended. It aids in the healing process. You should wait at least 6-8 weeks before doing more intense workouts, such as weight training. Heavy chest workouts should be avoided for even longer, up to three months, for bodybuilders who have undergone the double incision Top Surgery to avoid straining the incision scars.

Inquire with your surgeon about this. Some doctors recommend showering after 24 hours, however you should shower with your back to the shower head to avoid direct water spray on your healing scars. After that, carefully pat the chest dry and follow any ointment or dressing instructions the surgeon has given you. Some surgeons advise waiting until after your first post-operative appointment to shower. You can bathe following surgery, but avoid bathing in a deep tub to avoid flooding your chest. 6-8 weeks after surgery, you can utilize a hot tub for brief amounts of time. If you have any incisions that haven’t healed entirely, don’t use a hot tub. After six months, you can resume lengthier soaks.

Scarring can be reduced in a variety of ways, and your surgeon will offer specific recommendations. To avoid straining the wounds and generating bigger scars, your incisions will most likely be wrapped for a week or more after surgery. After surgery, wearing a compression vest can help reduce scarring. Numerous studies have shown that silicone gel and silicone gel sheets are efficient scar healers, and there are numerous alternative natural scar healers available. Move regularly accessed items down from higher areas in your home in preparation for your return after Top Surgery, as reaching up over your head immediately after surgery will strain the incisions and scars. Take that beloved cereal bowl off the third shelf and place it on the counter so you don’t have to reach up to grab it after surgery. Finally, for at least a year, keep your scars out of the sun or apply a powerful sunscreen.

Other Health Considerations with Top Surgery

Because no studies have followed the incidence of post-op breast cancer in trans guys, there is no conclusive answer. Because Top Surgery removes practically all breast tissue, the general consensus on the matter is that it dramatically reduces the chance of cancer. Less breast tissue means fewer cancer cells can survive. However, not all breast tissue is removed, and the idea ignores HRT: some trans men experience increased estrogen levels (through aromatase), which can raise the risk of breast cancer, even in those who have had Top Surgery. Personal and family health histories are also factors to consider.

At your yearly check-up, if you’re over 40, your doctor should undertake a breast examination using palpation of the chest and underarms. A CT or MRI should be obtained if any abnormalities are discovered.

Do you need a gender dysphoria diagnosis to get top surgery?

You must have persistent, well-documented gender dysphoria, according to the criteria. Ability to make an informed decision and consent to treatment. Have you attained the legal age in your nation to make health-care decisions? (age of majority or age 18 in the U.S.)

Can you get top surgery 15?

Top surgery is normally done after a person has started taking testosterone and has been presenting themselves socially as a man for a while. The physicians at UI Hospitals & Clinics adhere to the World Professional Association for Transgender Health (WPATH) standards of care, which require a single letter from a mental health specialist certifying readiness for surgery. Though the majority of people who get top surgery are over the age of 18, younger people may be considered if the patient, their legal guardians, and their mental health expert believe that it is necessary. Those who are mature enough to thoroughly understand the operation and have realistic expectations for the results are the ideal candidates for top surgery. Transmasculine people who plan to breastfeed should avoid male chest reconstruction.

Can breasts grow back after top surgery?

This is far from the case. The breast tissues can never grow back after being medically removed, whether you had a keyhole or double-incision mastectomy. Your doctor will remove around 95% of your breasts during an FTM procedure. Do not be concerned if a small amount of tissue remains after surgery. It was done on purpose to make your chest look proportionate and easy to contour rather than hollow and concave.

How do I talk to my insurance about top surgery?

This new guide will help you through the steps of obtaining insurance coverage for FTM Top Surgery, including how to appeal a rejection of coverage and how to appeal a denial of coverage.

In May 2016, the US Department of Health and Human Services issued a final rule prohibiting categorical exclusions in federally funded health plans. If your plan incorporates transition-related exclusions, your insurance company may be in violation of federal regulations.

The provisions of the regulation, which take effect on July 18, 2016, are not expected to be met immediately by insurance companies. This means that if they illegally deny you surgery coverage, it is up to YOU to pursue them.

“Categorical exclusions can be overcome and are now illegal in many cases.”

It’s worth noting that the guide was written by a non-binary person who is not on testosterone, lives in a place with no legal protections at the time of their experience, and has an insurance plan with exclusions—-yet their Top Surgery was nonetheless reimbursed! They’re now sharing how they achieved it with anyone who might find it useful.

Top Surgery Insurance Advice From a Supermom Who Won’t Take No For An Answer!