Limited Coverage of Gender-Affirming Breast and Chest Reconstruction in Insurance CPT Coding Criteria

Blasdel, Gaines; Nolan, Ian T; Harris, Alexander B; Young, Ezra; Hazen, Alexes

doi:10.1097/prs.0000000000007016

Cited by 6 publications

(5 citation statements)

References 3 publications

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“…These procedures may include nipple-areolar reconstruction as the nipple areolar complex differs in men and women, fat grafting or suction lipectomy to correct any contour irregularities or asymmetries. 10 The overall 30-day bottom surgery complication reported in this NSQIP data analysis is roughly 8%, which is much lower than the rates reported in the literature. Bottom surgery, particularly FtM is associated with high complications rates related to urological dysfunction.…”

Section: Discussionmentioning

confidence: 54%

“…The coverage may include the core procedure, for example, a mastectomy for chest reconstruction but coverage often times does not include necessary yet ancillary procedures surrounding a chest/breast reconstruction in the setting of GAS. These procedures may include nipple-areolar reconstruction as the nipple areolar complex differs in men and women, fat grafting or suction lipectomy to correct any contour irregularities or asymmetries 10 …”

Section: Discussionmentioning

confidence: 99%

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Gender-Affirming Surgeries

et al. 2022

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Background Gender affirmation surgery is an exponentially growing field within plastic surgery. The aim of our study is to analyze demographics, procedure type, trends, and outcomes in the surgical management of gender identity disorder in the past few years. Methods The American College of Surgeons NSQIP database was queried for the years 2015 to 2019. International Classification of Diseases codes were used to identify all gender-affirming cases. Patients were categorized by procedure type using Current Procedural Terminology codes for feminizing/masculinizing top, bottom and head/neck procedures. Patient demographics, comorbidities, and postoperative complications were analyzed using SPSS statistics software. A comparative analysis was performed among the procedure type. Results From 2015 to 2019, 4114 patients underwent a gender-affirming surgery (GAS) increasing the number of surgeries by over 400%, according to the NSQIP database. Demographics include age (mean = 32 years), body mass index (mean = 28 kg/m2), race (60% White, 22% unknown, 13% African American, 4% Asian, 1% other). Female to male procedures represented the most commonly performed (n = 2647; 64%), followed by male to female (n = 1278; 31%) with head/neck procedures representing 5% (n = 189) of all procedures. Top surgeries were also the most common (n = 2347, 57%), followed by bottom surgeries (n = 1578, 38%). The overall complication rate was 6% (n = 247), 2.1% (n = 4) for head/neck procedures, 8% (n = 134) for bottom procedures, and 3.5% (n = 84) for top surgeries. A reoperation within 30 days and related to the initial GAS occurred for 52 patients. Postoperative complication rates were statistically different between bottom surgeries compared with the top and head/neck procedure groups (P < 0.001). Increasing age and body mass index showed a significantly higher odds of having a complication. Conclusions Gender-affirming procedures have significantly increased over the past 5 years. Increased exposure through literature and research, as well as an improvement in social climates, including increasing insurance coverage have contributed to the expansion of these procedures. Low serious complication rates within 30 days prove GAS to be safe.

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Section: Discussionmentioning

confidence: 54%

Section: Discussionmentioning

confidence: 99%

Gender-Affirming Surgeries

et al. 2022

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“…The flaws of the RVU system have been shown to influence surgical decisions across specialties, affecting patient outcomes of all disciplines. 8,[20][21][22][23] These concerns may be reflected in the popularity of carve-outs (reimbursement agreements that exceed the gross recipient indicated by Medicare) and use of Healthcare Common Procedure Coding System codes in microsurgical breast reconstruction. Carve-outs, however, may facilitate additional inequities in reimbursement.…”

Section: Discussionmentioning

confidence: 99%

“The Cost of Doing Business: An Appraisal of Relative Value Units in Plastic Surgery and Other Surgical Subspecialties”

Shim

Stoffel

Neubauer

et al. 2023

Plastic &Amp; Reconstructive Surgery

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Background: The relationship between procedural complexity and relative value units (RVUs) awarded has been studied within some specialties, but it has not yet been compared across different surgical disciplines. This study aims to analyze the association of RVUs with operative time as a surrogate for complexity across surgical specialties, with a focus on plastic surgery. Methods: A retrospective review of surgical cases was conducted with the 2019 National Surgical Quality Improvement Program database. The top 10 most performed procedures per surgical specialty were identified based on case volume. Only cases with a single CPT code were analyzed. A subanalysis of plastic surgery procedures was also conducted to include unilateral and bilateral procedures with a frequency greater than 20. Results: Overall, operative time correlated strongly with work RVUs (R = 0.86). Orthopedic surgery had one of the shortest average operative times with the greatest work RVUs per hour, in contrast to plastic surgery, with the greatest average operative time and one of the lowest work RVUs per hour. Of the plastic surgery procedures analyzed, only five were valued on par with the average calculated from all other specialties. The most poorly rewarded procedure for time spent is unilateral free flap breast reconstruction. Conclusions: Of all the surgical specialties, plastic surgery has the lowest RVUs per hour and the highest average operative time, leading to severe potential undervaluation compared with other specialties. This study suggests that further reevaluation of the current RVU system is needed to account for complexity more equitably as well as encourage value-based care.

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“…Ensuring access to hormones is an essential harm-reduction strategy because it not only decreases the economic burden for transgender patients but also reduces the risk of non-prescription hormone use [16]. Given the high rates of mental health concerns and significant barriers associated with accessing appropriate hormone therapy, healthcare professionals must work alongside policymakers to reform insurance coverage to be more inclusive of transgender patients [17].…”

Section: Hormonal Therapymentioning

confidence: 99%

Journeying Through the Hurdles of Gender-Affirming Care Insurance: A Literature Analysis

Patel¹,

Camacho²,

Salehi³

et al. 2023

Cureus

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Gender-affirming surgery (GAS) has been proven to be successful in the treatment of gender dysphoria. The benefits of providing insurance coverage for transition-related surgeries far surpass the costs of suffering from persistent gender dysphoria, including many positive health outcomes such as decreased rates of substance use, psychiatric illness, and suicide. Despite being deemed a medical necessity, discrepancies in access to treatment and insurance coverage for GAS persist. The purpose of this review is to understand the impact of limited insurance coverage on the well-being of transgender patients. A comprehensive search was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in SCOPUS and PubMed databases using the terms "insurance" AND "gender affirming surgery." Articles in non-English languages were excluded. Data related to variations in insurance coverage for GAS in the United States were collected. Of the 67 articles reviewed, 29 met the inclusion criteria. When compared to the general population, individuals who identify as transgender have higher rates of being uninsured as of 2020, with only 30 states in the United States providing insurance coverage for transgender and gender nonbinary people. Of the 30 states, only 18 provide coverage for GAS, with chondrolaryngoplasty having the highest prevalence of coverage. As evidenced in our review, the persistence of complex insurance regulations impedes transgender individuals' access to equitable care. Overall, this literature review elucidates the variability in insurance coverage as it relates to gender-affirming care. Furthermore, this review highlights the need for additional health policy reforms, in addition to improving physician awareness regarding the hurdles of navigating the insurance world as a transgender patient.

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Limited Coverage of Gender-Affirming Breast and Chest Reconstruction in Insurance CPT Coding Criteria

Cited by 6 publications

References 3 publications

Gender-Affirming Surgeries

Gender-Affirming Surgeries

“The Cost of Doing Business: An Appraisal of Relative Value Units in Plastic Surgery and Other Surgical Subspecialties”

Journeying Through the Hurdles of Gender-Affirming Care Insurance: A Literature Analysis

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