FTM Top Surgery & Insurance Coverage: What You Need To Know

One of the biggest concerns of top surgery patients is its cost and if their insurance coverage will help cover the amount.

When doing your research in preparation for top surgery, it’s natural to have many questions: What is the cost of surgery? What additional expenses should I be ready for? What are my financing options?

As it tends to go beyond what many patients think top surgery costs, they explore their options and consult with their insurance providers.

The average cost for FTM top surgery in Ohio is between $6, 500 and $8, 500. The amount varies depending on certain factors such as body size and shape. The average cost is usually inclusive of the following:

• Surgeon’s fee
• Anesthesiologist’s fee
• Facility fees
• Pathology fees
• Post-operative fees such as medical compression vests, medication, paper tape, gauze, and scar care

Some surgeons will directly contact the insurance company to get the cost of the surgery covered, whether in whole or part. Other clinics ask the patient to pay in advance and apply for reimbursement through the provider after surgery.

Do Insurance Providers Cover Transgender Top Surgery?

Since 2013, some U.S. states have banned transgender exclusions in health insurance. These anti-discrimination policies protect LGBTQ+ people from unfairly denying health insurance coverage for specific procedures based on sexual orientation or gender identity.

Currently, 16 states, Washington D.C., and Hawaii have these laws in place. These include Oregon, California, Colorado, Vermont, Connecticut, Massachusetts, Washington, Illinois, New York, Nevada, Delaware, Pennsylvania, Michigan, Minnesota, Montana, and Rhode Island.

If you live in a state where transgender top surgery coverage isn’t mandated by law, you can still get your top surgery covered by health insurance. You simply need to find a provider that extends their health policy coverage to this procedure.

Insurance Providers That Cover Top Surgery

Our surgeons at Midwest Breast and Aesthetic Surgery accept FTM top surgery insurance offered by most major insurance carriers, including:

• Aetna
• Anthem
• Cigna
• Humana
• Medical Mutual of Ohio (MMO)
• United Health Care
• Medicare

Who Is Eligible For Insurance Coverage?

Coverage varies between companies in different states and the plans they provide. Therefore, it’s essential to read your insurance plan and look for any exclusions or limitations, especially if they pertain to transgender procedures when reviewing your insurance coverage. You can also call the company and ask:

• If the selected surgeon is a partner of the company and provided for by your specific plan;
• If your plan has out-of-network benefits, in case your surgeon is not a provider; and
• If your plan covers gender-affirming surgery.

The next step is to apply for preauthorization, or prior authorization, a claim that you submit to your insurance company to ask them to approve coverage before your procedure.

Typically, the application for preauthorization will include two documents.

The first is a letter from you to your health plan stating your request for the surgery to be covered and why you need the treatment.

The other is from a healthcare provider, such as a mental health expert or primary care provider. They will, as a professional, explain why the treatment you’re seeking is medically necessary for you. In some cases, your surgeon may be asked to provide a third support letter.

You’ll also need to submit other requirements. Depending on what your provider asks for, you may need to prepare the following:

• Proof of legal adult status
• Gender Dysphoria diagnosis
• An evaluation by a board of in-network doctors

You might be wondering: After I submit these requirements, will my request surely be granted? Is there a chance that my top surgery will still not be covered by insurance?

Unfortunately, denials are common. But it would be best if you didn’t get discouraged, as you have every right to appeal the decision. In some instances, the denial is due to the surgeon not establishing why the surgery is necessary for you.

The Affordable Care Act and The Patient’s Bill of Rights also add important protections in health insurance that affect transgender people. Coverage cancellations or denials simply because a person has come out as transgender is unlawful.

What Midwest Breast & Aesthetic Surgery Can Do For You

The ideal candidates for top surgery are patients who have been diagnosed with gender dysphoria and have already begun transitioning. At Midwest Breast and Aesthetic Surgery, we perform FTM surgery for qualified individuals.

Top surgery takes an average of 2 – 3 hours to complete under general anesthesia. Results are immediately visible, but it may take 3 – 6 months for them to settle.

Our team will gladly work with your current insurance provider to cover the expenses for top surgery. After your initial consultation, we will submit a pre-authorization request for you.

Schedule an appointment with Ohio’s leading board-certified plastic surgeons today.