Using Insurance for Facial Gender Confirming Surgery or "FFS"

NEW: My presentation on FGCS Surgery Techniques

One of the greatest joys in my trans community work is helping people navigate Facial Gender Confirming Surgery. These procedures are also called Facial Feminization Surgery or FFS, but in agreement with the experts, I've shifted to using FGCS. In NY, we have the benefit of a clear history of coverage through Medicaid, and plenty of pro-bono legal teams able to help patients with denials. Resources in other locations are variable, but I'm attempting a general starter guide to FGCS through insurance. This guide may also be useful for people planning other procedures considered “cosmetic” and/or explicitly listed as not covered under their transgender benefits (breast augmentation, body contouring, facial masculinization surgery, etc.)

Please first read this resource for a general overview of insurance utilization for trans surgery. I cannot tell you what insurance plan to get that covers FGCS, there are too many variables. Every insurance company is "difficult" to work with. I always advise people to try with the insurance they have before they switch to another plan. This guide is “201” level, geared towards those who find themselves covered with an ACA exchange plan or private insurance, as Medicaid processes are much more state specific. However, I personally know multiple people who have achieved coverage for FGCS through state Medicaid in both NY and California. 

I am working from the perspective that you are unable to pay in full and be reimbursed. Regardless, I recommend that you fight everything out in the preauthorization/pre service review process, and not after you have already paid and might be left holding the bill. This means that the surgeon is either already in network with your insurance and is willing to send a prior authorization, or has an office willing to do the legwork of doing a letter of agreement with your insurance. There are “301” level topics not covered here- going out of network to an office who will only give you CPT codes performed, getting a “network exception” to go to a provider with skills not available among in-network surgeons, etc.

Before getting into the nitty gritty details, let me be real with you, and let me be hopeful. I can't guarantee that you'll achieve coverage, but depending on how your insurance benefits are regulated and the support resources you have access to, it's definitely worth trying. This process will be long and draining, but it is worth it. Everyone who is able to fight through it cracks the door open a little wider for the next person. It's hard for any person to find their voice to self-advocate when such deeply personal needs are up for debate and judgement as "cosmetic" among random insurance company reviewers. Ask to speak to people's supervisors. Get a bossy friend to make phone calls with you while you are dealing with the process. The structure of this system sucks, but it's the one in which you find yourself and it is your responsibility to make it work for you.

First Steps

1.      You need an understanding of your insurance benefits in general: What would any covered surgery cost you? Do you have out of network benefits, or are you limited to providers in the network? Do you have a deductible to meet? Co-insurance past that? What's your out of pocket max? 

2.      Next, you want an awareness of any explicit inclusions or exclusions for transgender care in your "Certificate of Coverage," the document that lays out what is covered in what circumstances. You should be able to download this document through a web portal, but if not, you are legally entitled to a paper copy. If there is a section on transgender care that explicitly denies coverage for the procedures in Facial Gender Confirming Surgery, as many do, you can still attempt to advocate for them to be deemed medically necessary. If the insurer refuses those attempts, you can appeal externally, but that will almost certainly require professional legal support.

3.      Finally, you should have an idea of your local resources. Are there transgender advocacy groups? LGBT legal service projects? Support groups? This document is a general guide to national resources, but because of the state-specific nature of most insurance regulation, I highly suggest you attempt to reach out to local experts who are better able to advise you to your situation. Additionally, planning and recovering from any trans surgery is hard! This could be a good time to join (or form!) a support group of people dealing with similar issues to you to help keep up your strength and spirits throughout planning and recovery.  For people without local connections, the facebook group, “FFS Facial Feminization Surgery / Transgender TG TS” and the FFS Forums on susans.org are good places to seek community support as well.

Finding a Surgeon

Integral to this whole process is the FGCS surgeon. A surgeon who takes your insurance, hopefully in-network or willing to do the legwork of a single case agreement, with whom you are ready to move forward in planning surgery. This might be the hardest part- no one should have to compromise quality, and the big names in FGCS have historically not taken insurance, though it’s my observation that this is rapidly changing. The blossoming of academic medical centers offering transgender surgical care also means that more well respected surgeons, with appropriate craniofacial and maxilliofacial reconstructive training, are able to do procedures through insurance. See the list at the end of this article for surgeons who will accept some form of insurance benefits directly.

What makes someone a FGCS surgeon anyway? I recommend the pioneer of FGCS, Dr. Douglas Ousterhout’s book, “Facial Feminization Surgery: A Guide for the Transgendered Woman” for those looking to learn more about what skill and training is involved and a breakdown of procedures as he performed them, but I’ll attempt to summarize. FGCS is a collection of procedures designed to change the bone structure of the face and reshape features that resulted from testosterone exposure. This could include either shaving down or entirely re-contouring the forehead/eyesockets/sinus area using osteotomies (cutting and repositioning bones), shaving the jaw line or a sliding genioplasty (reduction and/or re-positioning of the jaw bone), lifting the upper lip, rhinoplasty (“nose job”), and bringing the hair line further forward, in addition to other various soft tissue facial adjustments and reduction of the “adam’s apple.” Surgeons who practice facial gender confirming surgery often have special training in reconstructing facial features using bone grafting beyond a traditional plastic surgery residency.

Once you've identified a surgeon who takes your insurance, ask them to submit a preauthorization. This is their communication with the insurance company verifying that the procedure is covered. They submit their own information, information about the procedure being performed, and information about you. 

The Letters

They will need letters of support from you for the preauthorization, following WPATHs Standards Of Care. Though specifics required by insurance vary (and might be laid out explicitly in your Certificate of Coverage) I recommend every person have three letters of support.

1.       A letter from your primary care provider or whoever prescribes your hormones. In addition to following WPATHs SOC format, it is helpful if it is specifically tailored to FGCS. Ultimately this letter is between you and your provider, but here is some sample language that has been helpful to patients I've worked with: "Patient X has been adherent to two years of hormone replacement therapy including (specific estrogen regimen.) In Patient X's case, she has achieved the full extent of facial feminization that can be expected with hormone therapy. Hormone therapy alone has not sufficiently treated her gender dysphoria, and the next step in her treatment plan is Facial Gender Confirming Surgery." This could be replaced with language about how you are not eligible to take estrogen therapy for whatever reason, including fancy language for just not wanting to.

2.       Two letters from mental health providers. Your insurance might have a requirement about length of time in care with them, or degree level. Generally, one provider should have a doctoral level degree (PhD, DSW, Psychiatrist MD) and the other can have a masters level degree (MSW, MHC, etc.) These letters, in addition to following the WPATH standards of care, are the place to communicate the severity of the dysphoria- does your dysphoria impede activities of daily living, for instance by making you unable to leave for work on time? Have your facial features compromised your safety, making you a target for harassment and violence?

Some people stress additional mental health conditions (anxiety, depression, ptsd) in these letters. I don't philosophically agree with this. FGCS is a treatment for gender dysphoria related to the secondary sex characteristics in the face, not a treatment for anxiety caused by the experience of having gender dysphoria or being a transgender person in an unkind world. Based on my conversations with friends who are very satisfied with their FGCS, I assure you that no surgery can completely resolve that anxiety. I could go on about this, but I hate to further the expectation that you must be very mentally ill in order for the "extreme" treatment of FGCS to be warranted. However, this has been a persuasive strategy in some cases.

Each letter should state "this procedure is medically necessary treatment.” With all letters, I advise providers to be as authoritative in their tone as possible, and to explicitly claim an expert status if appropriate. If it is substantial, they should name their years of experience working with transgender patients. If they are a member of WPATH or other applicable professional associations, they should name that. If they have referenced expert guidelines or current research in devising your care plan, they should state that and provide citations. Their credential as an MD/DO/NP/PA/MSW/PHD and signature on an essentially form WPATH conforming letter are not sufficient- they need to impress upon the medical reviewers that they are not simply approving your referral request, but are guiding your care as a treating provider, and that this surgery is part of your care plan. 

The Denial

Now you will be denied! I tell everyone to plan for an initial denial- even if FGCS is covered in your plan clearly, it’s likely that portions of the procedure will be denied as cosmetic. This should be sent to you in written form, with the specific reason for the denial included. Please keep track of the mail being sent to the address on file with insurance, as you often are only able to appeal within certain time frames from the initial decision. This denial should also lay out your options for appeal- both internal (basically, asking the insurance company to reconsider) and external. 

This is the point at which you will likely need legal support. The format for an appeals process and regulations/law/policy to cite within it vary widely depending on the mix of state and local regulations that apply to your specific plan. This is also the point at which general 201 level guidance ceases to be useful. As many professions say, “past performance does not guarantee future results.” However, the tide of change is beginning to roll in- often where Medicaid begins, private plans will be forced to follow, so the clear coverage in California and New York bodes well for everyone.