Gender Affirming Surgery
If you would like assistance finding a surgeon in-network with a particular insurance company, completing an appeal, navigating the surgery referral process in general, please set up an appointment. Check out the "consulting services" section for more information about what services are available to those undergoing gender affirming surgery.
Simplified surgery referral flow
Primary Care Provider writes medical clearance letter
Mental Health Provider writes mental health clearance letter
2nd Mental Health Providers writes second mental health clearance letter (only for genital/reproductive system surgeries--orchiectomy, hysterectomy, vaginoplasty, metoidioplasty, phalloplasty)
Letters are sent to surgeon's office
Primary care office submits prior authorization (request for coverage) to insurance for consult appointment (if needed)
Insurance approval of prior authorization for consult appointment (if needed)
Schedule consult appointment with surgeon
Consult occurs and both surgeon and client agree to move forward with surgery
Schedule surgery date
Surgeon’s office submits prior authorization to insurance requesting coverage for surgery (usually 1-3 months prior to surgery date)
Insurance approval of surgery prior authorization
WPATH SURGERY Letter template
Unsure what to include in a support letter for surgery? These two resources can be helpful:
Readiness Questionnaire (prepared by JM Jaffe for Lyon-Martin Health Services)
To be given to a trans client to complete prior to their appointment with the mental health provider
TransLine WPATH Letter Template (prepared by JM Jaffe for TransLine)
Example of surgery support letter
find a surgeon
If you would like to try to have your insurance company pay for your surgery, I would recommend either contacting surgeons and providing your insurance information to see if they are contracted and in-network with your plan, or contacting your insurance company directly to see if they have a preferred list of surgeons they are contracted with that do the surgery you are seeking. If your insurance company cannot provide a surgeon that is in-network to do the surgery you want, you should be able to try to have your insurance cover an out-of-network surgeon--especially if you live in a state with gender non-discrimination laws in health insurance such as the ones listed in the section below entitled "What are the laws in my state?". If you live in one of these states and your insurer does not have an in-network surgeon willing and able to do the surgery, they are required to find an out-of-network surgeon to contract with based on network adequacy laws. To get this process started, your primary care provider should submit a prior authorization to your insurance company with your WPATH letters requesting a consult with the out-of-network surgeon.
Bay Area Surgeon List (last updated 3/2019; prepared by JM Jaffe for Lyon-Martin Health Services)
insurance denial navigation in california
Surgeon’s office submits a Prior Authorization, a request for insurance coverage of the surgery submitted to the insurance company. Include any supporting documents, like the WPATH letters for surgery, visit notes, any insurance bulletins about gender non-discrimination laws in the state.
If the Prior Authorization is denied, do an Internal Appeal. Follow the insurance company's protocol to submit an appeal to that insurance company's appeals or grievances department. Include the same documents included with the prior authorization along with an appeal letter explaining what has occurred and how a denial of medically necessary care is illegal under the state’s non-discrimination laws. Including additional publications backing up the argument made can strengthen the case.
If the Internal Appeal decision upholds the prior authorization denial, do an External Appeal (In CA, submit an Independent Medical Review to the Department of Managed Health Care). Include all documents submitted with the Internal Appeal.
Transgender Law Center's Guide: How to Appeal your Health Care Denial
If you would like assistance in appealing your denial, contact me
what are the laws in my state?
The following states have gender non-discrimination laws in health care coverage and provision (insurance companies based in these states cannot exclude coverage of medically necessary care related to gender transition, including hormones and surgery):