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Navigating insurance for top surgery can be a challenge. Insurance plans often require that teens meet certain prerequisites prior to top surgery. We鈥檙e here to walk you through the process, coordinate care with your insurance provider, and answer any questions you may have.

The process

To get started, we will set up a surgical consultation appointment. We鈥檒l review your insurance coverage and discuss what is required for authorization. Most likely, your insurance company will require a full physical exam along with two approval letters. Once all required paperwork is completed, we will submit it for authorization to your insurance company and keep you informed of the status of your application. 听听听听

Don鈥檛 get discouraged by an initial denial. More often than not, appeals are necessary before surgery is approved by insurance providers. We鈥檒l partner with you in submitting an appeal letter and take action to optimize the approval process. Once the surgery is authorized, the surgery date will be confirmed. If you have any questions along the way, please don鈥檛 hesitate to ask. We鈥檙e dedicated to doing whatever we can to obtain approval.听

Tips for success

• Investigate your insurance plan and read the fine print on what is covered and what鈥檚 not covered. Ask what stipulations there are with 鈥渢op surgery鈥� or 鈥済ender reassignment surgery,鈥� and inquire about the appeal process鈥攈ow often requests are appealed and how often they eventually lead to approval. If the insurer says there is no coverage, you鈥檒l have time to explore other plans.
• Look for key language regarding age. If your insurance policy specifically states that a person must be 18 years old for coverage, then we must wait until the patient is that age. If your policy does not specify an age, occasionally we have success by appealing with letters of support for teens under the age of 18.
• Keep in mind that procedures deemed medically appropriate are covered, while cosmetic procedures are not. For example, top surgery can be proven as medically appropriate. Liposuction cannot.
• Make sure that approval letters are in place. Most insurance plans require approval letters: (1) a letter (or two) from a professional mental health provider attesting to gender dysphoria (a conflict between assigned sex at birth and gender identity), and sometimes (2) a letter from a doctor stating that 12 months of hormone therapy has been completed (this can vary by plan). 听听