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Insurance Barriers And Appeals For Facial Feminization Surgery: A Cost Analysis
Allison C. Hu, BA, Brian N. Dang, BS, Anthony A. Bertrand, MD, PhD, Candace H. Chan, BS, Justine C. Lee, MD, PhD.
University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA.

PURPOSE: While facial feminization surgery (FFS) has been shown to be an integral aspect in treating gender dysphoria, insurance coverage is unpredictable and often unfavorable. Navigating insurance companies is a stressful and laborious process for both the patient and healthcare provider. The purpose of this study is two-fold: 1) to determine barriers to care and the resultant time and monetary burden imposed on FFS patients and providers; and 2) detail how we combat the appeal process to help advise other plastic surgeons on how to handle insurance denials. METHODS: We retrospectively identified patients who underwent facial feminization surgery at our institution from January 2018 to November 2019. Demographic, clinical, and administrative data were extracted. Barriers to care components such as distance traveled, time to approval, surgery wait time, and reasons for insurance denials were analyzed. A societal cost analysis was performed by surveying staff members and patients to determine the time spent at each consecutive step of the insurance appeal process and combining these times with average compensation data to calculate overall cost. RESULTS: Of the 43 total patients who have been consulted for FFS, 18 (41.9%) have been approved by insurance, 16 (37.2%) have surgery scheduled, and 11 (25.6%) have completed FFS surgery. Average age of included patients at initial consultation and surgery was 36.9 (range 19.5-72.5) and 34.6 (range 21.9-63.3), respectively. Patients travelled 39.7 miles (range 3-211) to receive care for FFS and took 4.1 years (range 1.0-10.6) of hormone replacement therapy prior to surgery. Most patients had private insurance (n=31, 72.1%), followed by Medi-Cal (n=8, 18.6%), and Medicare (n=4, 9.3%). A total of 13 (65.0%) patients were denied on initial authorization request whereas 7 (35.0%) were approved, of which 2 (10.0%) were transgender health care riders. While approval on initial authorization request for privately insured patients took on average 1.7 months (range 0.7-2.8), those who were denied and undertook the appeal process were approved at 6.3 months (range 2.2-10.0). In contrast, insurance approval for patients with Medi-Cal took 1.3 months (range 0.3-2.0). The most common reason for insurance denial was because the procedure was deemed cosmetic and/or not medically necessary. Of the 11 patients who completed FFS, a total of 3 (27.3%) surgeries were cancelled or rescheduled due to insurance related issues. The appeal process for privately insured patients took an average of 6.77 (range 3-15) hours of institutional time and cost $475.92 (range 216.10-1059.50) per patient. CONCLUSION: This study highlights the challenges associated with insurance denials, and the time and societal cost of the appeal process. Barriers to facial feminization care include physician availability, travel distance, requiring prior authorizations, and frequent coverage denials for reasons such as the surgery being too "cosmetic" or lack of medical necessity. It is important to continue to perform outcomes studies in this underserved population, no matter how small the sample size, to prove the functional and quality of life benefits of facial feminization surgery.


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