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Is Top Surgery Medically Necessary?

Gender-affirming surgery procedures are medically necessary reconstructive surgeries that are performed to treat gender dysphoria. Top Surgery is the most commonly performed gender-affirming surgery for trans masculine people and evidence shows that it improves quality of life and reduces the symptoms of gender dysphoria.

Despite the fact that the medical necessity of Top Surgery is now widely acknowledged, insurance companies still routinely deny coverage for the procedure. Confirmation of the medical necessity of Top Surgery is not only required by insurance companies, but trans and non-binary people are often called on by friends, family and loved ones to prove why they need surgery. If you're being asked to explain why Top Surgery is medically necessary for you, this summary of evidence-based science showing the effectiveness of Top Surgery can serve as a useful tool in the arsenal of your defence.

Is Top Surgery Medically Necessary?


Medical Necessity Defined

Medicare defines medical necessity as: "Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice." In other words, the treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem.

Blue Cross Blue Shield's definition of medical necessity asserts that the treatment in question must be clinically appropriate and in accordance of generally accepted standards of medical practice.

"Generally accepted standards of medical practice means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of Physicians practicing in relevant clinical areas and any other relevant factors."


The Scientific Evidence That Backs Top Surgery

There is a well established body of peer-reviewed medical research that demonstrates the effectiveness and medical necessity of Top Surgery as a form of treatment for many people diagnosed with gender dysphoria.

Proven Benefits of Top Surgery:

1. Top Surgery decreases body dissatisfaction and gender dysphoria in social interactions.
Tim C. van de Grift et al., Body Image of Transmen: Multidimensional Measurement and the Effects of Mastectomy, 13 J. of Sexual Medicine 1778, 1785 (2016). [FULL TEXT]

2. Top Surgery allows people to be recognized as male by others and facilitates living in accordance with a male social role.
Claes K, D'Arpa S, Monstrey SJ. Chest Surgery for Transgender and Gender Nonconforming Individuals. Clin Plast Surg. 2018 Jul;45(3):369-380.

3. Top Surgery has a high satisfaction rate and improves quality of life. In this 2017 study, the satisfaction rate by trans men after having Top Surgery was 94%. Respondents also reported a relatively positive quality of life, confirming that medical transition alleviates feelings of gender dysphoria and improves life satisfaction.
Tim C. van de Grift et al., Surgical Satisfaction, Quality of Life and Their Association after Gender Affirming Surgery, J. of Sex & Marital Therapy 1, 4 (2017). [FULL TEXT]

Other studies have also shown that Top Surgery has a clear positive impact on the lives of patients:


Experts Agree On Top Surgery

At this time, there is no physician specialty board or society for Gender Surgery that oversees or certifies surgeons practicing in the field. However, leading medical organizations in the United States agree that gender-affirming care is the most effective treatment for gender dysphoria. The American Medical Association, the American Psychological Association and the American Psychiatric Association have all issued position statements supporting coverage for medically necessary treatment as determined by a patient and their health care provider.

The World Professional Association for Transgender Health (WPATH) has also issued a position statement on the medical necessity of gender-affirming surgery, noting that clinical and peer-reviewed evidence shows that gender-affirming care has proven to be beneficial and effective in the treatment of gender dysphoria and plays an "undisputed role in contributing toward favorable outcomes."

Furthermore, the WPATH Standards of Care recognize that for those who do not experience relief from other treatments, "surgery is essential and medically necessary to alleviate their gender dysphoria . . . relief from gender dysphoria cannot be achieved without modification of their primary and/or secondary sex characteristics to establish greater congruence."

Dr. Gabriel Del Corral - Top Surgery in Baltimore and Washington D.C.Among Gender Surgeons, there's no debate about the life-saving nature of Top Surgery for patients who require it to align with their gender identities. "It allows them to feel comfortable in their own bodies," says Dr. Gabriel Del Corral, a plastic surgeon with MedStar Health in Baltimore and Washington D.C. who specializes in gender-affirming surgeries. "We're talking about a population where 40 percent have attempted suicide, and for some patients, the surgery can be the final step that allows them to finally flower into who they are as a person."


Medical Necessity and Insurance Coverage

"Professionals who provide services to patients with gender conditions understand the necessity of SRS, and concur that it is reconstructive, and as such should be reimbursed, as would any other medically necessary treatment." — Principles of Transgender Medicine and Surgery, edited by Randi Ettner, Stan Monstrey, Eli Coleman, 2007.

Health insurance companies in the U.S. provide coverage for health-related services that they determine to be medically necessary and the majority of insurance company medical policies on gender dysphoria treatments now recognize Top Surgery as medically necessary for adults. Nevertheless, some insurance companies still deny coverage, forcing patients to rightfully resort to appealing the decision. Proving that the surgery is a medical necessity is the key to overturning the insurance company's decision.

What About Minors?

Despite evidence of high satisfaction (and no regret) among minors who underwent Top Surgery, some insurance companies in the U.S. require patients to be 18 years or older to receive coverage for Top Surgery. Refusing medically necessary treatment on the basis of age is in violation of federal nondiscrimination law. Furthermore, this stance is not in alignment with the medical literature, opinions of Gender Surgeons, or the insurance companies that do recognize the medical necessity of Top Surgery for those under age 18. When Top Surgery is medically necessary in a minor, delaying surgery risks immediate mental health repercussions and prolongs the negative physical effects of chest binding.

While it's very important to meet the required criteria to get insurance coverage, it's also true that medical necessity can override other criteria set out by an insurance policy, including age.

"Trans Family SOS has provided guidance in multiple cases where the subject was a minor, and every one of those appeals was successful, based in part on the strength of the documentation proving medical necessity," says Kathie Moehlig, a parent advocate and the founder of Trans Family SOS, a San Diego-based organization that provides trans youth and their families assistance with health care and insurance, school policies and legal issues.

Not every person with gender dysphoria has the need to undergo surgery, but for those who do, Top Surgery is medically necessary and has been scientifically proven to be effective at treating gender dysphoria and improving quality of life, in both adults and minors.

Related links:

Insurance How-To Guide
This guide walks you through the process of getting insurance coverage for Top Surgery, including how to file an appeal and reverse a denial of coverage.

Health Insurance - Appealing a Denial
Learn about the different types of appeals available to challenge a denial of coverage for transgender-related health care. This section covers how to appeal medical necessity denials only, not denials due to blanket exclusions. It also covers things outside of the formal appeals process that might help overturn a denial.

Your Best Defense: the Letter of Medical Necessity
The Letter of Medical Necessity is a potent tool. It is a LEGAL document wherein your doctor argues why you need a specific medical treatment or test.

 

Last updated: 11/18/20


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