A. Almazan2, E. Boskey1, O. Ganor1 1Boston Children’s Hospital,Plastic And Oral Surgery,Boston, MA, USA 2Harvard Medical School,Boston, MA, USA
Introduction: The criteria used to judge the medical necessity of a surgery can vary substantially between insurance providers and related procedures. Despite procedural similarities, insurance policies enforce different requirements for reimbursement of reduction mammoplasty (RM) in cisgender women, gynecomastia excision (GE) in cisgender men, and gender-affirming mastectomy (GAM) in transgender men. In this study, we examine how analogous procedures may be treated differently for patients of different genders, and we identify differences in coverage policies across insurance providers.
Methods: For each procedure, we examined the medical necessity criteria from the websites of the 9 largest national insurance networks that have national coverage guidelines, the 6 federal plans available through the Federal Employees Health Benefits plan, and 5 state plans for a large national network with state-based coverage policies. Plan policies were reviewed to determine coverage and identify standard medical necessity criteria for each procedure. For each plan, we recorded whether each procedure was covered and whether each medical necessity criterion was adopted.
Results: Coverage was highly variable between procedures. None of the plans excluded RM from coverage. 2 national networks, 2 federal plans, and 2 state plans excluded GE. 2 federal plans excluded GAM. Minimum age was the medical necessity criterion with the most variability between procedures. 5 of the 14 policies that cover GE explicitly required patients to be over the age of majority, compared to 10/20 RM policies and 16/18 GAM policies. GAM was the procedure with the most variable criteria between policies, with 10 different combinations of 5 criteria observed.
Conclusion: Insurance coverage and restrictiveness of medical necessity criteria for breast tissue removal are highly variable. Coverage for GE is fairly limited, and coverage exclusions for GAM exist despite the passage of transgender-specific insurance non-discrimination laws. Medical necessity criteria for RM and GE are somewhat inconsistent across insurers. Criteria for GAM are even more variable, despite the existence of published standards of care for transgender patients. Improving the consistency of insurance coverage for breast tissue removal, and streamlining procedure guidelines, has the potential to streamline the process of care.
