How to Approach Getting Insurance Coverage for a Trans Surgery | Point of Pride

The task of approaching your insurance company about your gender-affirming surgery can seem like an overwhelming task. There is so much jargon and industry-specific language that sometimes it can feel like they’re trying to keep you in the dark. You’re not alone – unfortunately, almost all trans folks who try to get insurance coverage for their trans-related procedures face these same challenges. By asking the right questions, you’ll have a better understanding of exactly how you can fight for the coverage you need.

You’ll want to start with your surgeon. There is a lot of information on the insurance side that’s dependent on how the surgeon will bill the procedure to your insurance company.

Questions to ask your surgeon:

First, you’ll want to check that they plan to/are able to bill your insurance.

• If they don’t plan to bill your insurance, you’ll still want to get the rest of the information below. There may be a way for you to submit the charges to your insurance yourself and be reimbursed for at least some of the charges.
• You’ll also want to ask, if they do not plan to bill your insurance, if they’ll still be willing to submit a prior authorization on your behalf, if required.

What CPT/HCPCS (pronounced "hick-pick") codes do they plan to bill for your procedure?

• There are typically a few codes. These codes are usually 5 numeric digits, occasionally with a modifier afterwards. For example, one of the more common codes used for a trans masculine top surgery is 19303 (Mastectomy, simple, complete), with the modifier 50 to indicate that it would be performed bilaterally, or on both sides.

What ICD-10 diagnosis codes do they plan to bill for the procedure?

• This is something that they or you may need to contact your therapist about. ICD-10 Diagnosis codes are a letter, with a few numbers after. For example, F64.9 Gender identity disorder, unspecified.
• If the code they give you is all numeric, such as 302.85: Gender identity disorder in adolescents or adults, they’ve given you an older code which stopped being used in October of 2015. Using an ICD-9 code may delay the process, so be sure your code is an ICD-10 Code.

Questions to ask your insurance provider:

Next, you’ll want to contact the member services department of your insurance. Their phone number should be on the back of your insurance card. Be prepared to confirm any of the following: your name, as they have it on their records, address, phone number, ID number or insurance ID.

"Is CPT/HCPCS code ___ a covered service for diagnosis code ___?"

• If No:

1. What is the appeals/exceptions process?
2. How do you file an appeal?
3. How long will that take?
4. How will you be notified of the result?

• If Yes:

1. Is a prior authorization required?
2. What is the criteria for approval? (Ask them to email you the policy statement – it typically includes all of the information that you need to get to them in order for them to approve the procedure).
3. How long will that take to process your PA once they receive it from the surgeon.
4. How will you be notified of the result?
5. What is your deductible/max out of pocket/copays?

If your surgeon does not plan to bill the procedure, you’ll also want to ask if you can submit claims on your own for reimbursement.

1. What documentation will you need to submit to them to have the claim paid?
2. Where should you send documentation?
3. If the claims are paid, how long will it take for you to receive reimbursement?
4. How will the reimbursement be paid?

With these questions answered, you’ll be better prepared to handle the process of navigating your medical coverage and having your gender-affirming surgery covered.

If you get stuck

If you find you’re getting stuck at a particular step or don’t know where to go next, there are resources available to assist you.

Contact your insurance company and request a supervisor:  they’re usually more knowledgeable about the ins and outs of your plan and may be able to help untangle a problem on the insurance side.

Still stuck? Contact your surgeon’s office: they work with insurance companies and medical coding daily and should be able to help navigate any issues. If you’re having your surgery through a hospital, many hospitals have a patient care coordinator on staff and part their job is to help you navigate the insurance and billing process. They’re often quite knowledgeable about tips and tricks to get your coverage unlocked.

In the end, remember that you are your own biggest advocate. Don’t be afraid to call and ask as many questions as you need because your health and well-being are your responsibility and no one knows you better than you.