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Additional information for
insurance coding appeals process
This information is pulled directly from “Gender Reassignment Surgery
Model National Coverage Determination,” a toolkit created by the
Transgender Medicine Model National Coverage Determination Work-
ing Group with the assistance of Nick Gorton, MD of Lyon-Martin in San
Francisco:
“The patient’s specic insurance plan has a transgender
care exclusion in their coverage. Most insurers have an ex-
clusion of coverage for transition-related coverage as their
standard language and do not remove it unless a state has
issued guidance that says that exclusions of trans care are
illegal, or the plan receives federal funds to pay for premi-
ums (or payment for a third party administer), such as a fed-
eral or state marketplace plan, Medicare or Medicaid pro-
grams (many states are out-of-compliance with the federal
rules for their Medicaid programs). This is the most com-
mon, and most folks don’t know they have an exclusion un-
til they are told where to look. This does not mean that it is
impossible to get care covered, but the appeals process is much harder.
Coverage for specic procedures: Some coverage is categorically excluded because
they are viewed as cosmetic (i.e. breast augmentation, body contouring, facial femi-
nization procedures) - generally speaking, these are hard to appeal and clearly delin-
eate why they are medically necessary to meet the insurer’s standards. Some “sub-
procedures” are also not covered, even if they main procedure is covered (i.e. double
mastectomy is covered for transgender men, but not nipple reconstruction; phal-
loplasty may be covered, but the testicular implants are not, often citing cosmetic
purposes) - when this occurs, the service is easier to appeal, because most of these
procedures are available to cisgender people, and the case can be made that the
“cosmetic ruling” is being applied to trans people for the sake of denying care (i.e. sex
discrimination).
Coverage issues can occur when someone is getting a “sex-specic procedure” such
as a pap smear or a PSA testing for prostate exams, this is typically related to what
gender marker the patient currently has on their health insurance account. While this
discrimination is illegal, this happens with some frequency, but can be xed using KX
or 45 modier. This is more of an educational issue to medical providers, but most
do not know that they can code in this fashion to assure that their patient’s care gets
covered.”
Sources:
www.cms.gov/medicare/coverage/determinationProcess/downloads/Kalra_comment_01022016.pdf
www.transline.zendesk.com/hc/en-us/articles/229372908-Coding-for-Transition-Related-Care
The Campaign for Southern Equality gives special thanks to Kinneil Coltman of Carolinas
Healthcare and Dr. Jennifer Abbott of Western North Carolina Community Health Services
for their assistance with compiling this information.