Health coverage guide

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Health Care Provider Letters

Letters from Health Care Providers

In addition to the letter you send to your insurance asking for your transition-related procedure to be pre-approved, your doctor or health care provider should also submit a letter explaining why the treatment is medically necessary for you. Your doctor can also include medical documentation about your diagnosis and course of treatment.

A transmasculine doctor with his computer.

 

Your insurance plan might have specific instructions about the type of medical documentation you need to provide or about the doctor who can provide the letter. For example, some insurance plans require you to provide letters from two doctors, or require a letter from a doctor with a specific type of accreditation (such as a mental health provider). Some insurance plans require specific information, like how long ago you were diagnosed with gender dysphoria or what treatments you’ve received in the past.

You should check your member handbook to make sure that your provider letter meets all the requirements. You should also send your plan policy to your provider so they are aware of the areas their letter will have to address.

 

Provider letters should typically include:

  • A statement that, in the doctor’s professional opinion, the treatment is medically necessary and the appropriate step in the course of care for the patient’s gender dysphoria. Some plans also require the provider to include codes for specific treatments or diagnosis. 
     
  • A brief description of the patient’s history of care. This can include, for example, how long they have been a patient of the provider writing the letter, when and by whom they were diagnosed with gender dysphoria, the symptoms of gender dysphoria that they are exhibiting, how long they have been living according to their gender identity, and what transition-related treatments they have received so far.
     
  • An explanation of why this procedure is medically necessary for this patientIt is recommended that the letter refer to the criteria in the World Professional Association for Transgender Health’s most recent Standards of Care, and demonstrate why the patient meets those criteria. The letter can also discuss the positive impacts that undergoing the procedure is expected to have on the patient’s health and the negative impacts that not receiving the treatment would likely have. In some cases, the letter should also discuss why other treatments that the patient has already received, like counseling, hormone therapy, or previous surgeries, have not fully resolved the patient’s gender dysphoria.
     
  • Relevant medical research. If possible, the letter should refer to studies demonstrating the effectiveness and medical necessity of the specific treatment that the patient is seeking. The letter can also refer to guidelines and statements by medical organizations that recognize that transition-related treatments for gender dysphoria generally are necessary and effective and that the World Professional Association for Transgender Health (WPATH) Standards of Care provide the established standards of care for gender dysphoria. The letter can also refer to WPATH’s specific 2016 guidance on the medical necessity of coverage for treatment for gender dysphoria in the U.S. and WPATH’s recommended benefits policy document. See below for examples of studies and statements that can be cited in a letter or included as supporting documentation.
     
  • If appealing a denial, the reason why the denial was incorrect (we recommend consulting a lawyer or clinic for assistance with any appeal): If the letter is being provided to appeal a denial that has already happened, it should quote the reason given in the denial letter and directly address why that reason is inappropriate. Sometimes, the denial will happen because the plan excludes a particular procedure (for example, facial feminization surgery or nipple reconstruction). In these cases, it will be particularly important to discuss about why that exclusion should not apply in the case of this particular patient, and why this treatment is medically necessary to treat the patient’s gender dysphoria. WPATH’s Standards of Care and guidance on medical necessity, referenced above, might be particularly helpful in these cases.
     
  • Health care provider’s credentials and contact information. The letter should include the doctor’s or health care provider’s licensing number, accreditation, and contact information in case more information is needed. It can also include information about the provider’s experience treating patients with gender dysphoria.

Resources and Supporting Evidence for a Provider Letter

The letter can refer to or include resources such as these for supporting evidence:

Examples of published medical studies demonstrating that transition-related treatments have a significant effect in alleviating gender dysphoria:

  • Examples of published medical studies on transition-related care generally:
    • Owen-Smith AA, Gerth J, Sineath RC, et al. Association between gender confirmation treatments and perceived gender congruence, body image satisfaction, and mental health in a cohort of transgender individuals. J Sex Med. 2018;15(4):591-600. doi:10.106/j.jswm.2018:01.017.
    • Witcomb GL, Bouman WP, Claes L, Brewin N, Crawford JR, Arcelos J. Levels of depression in transgender people and its predictors: Results of a large matched control study with transgender people accessing clinical services. J Affect Disord. 2018;235:308-315. doi:10.1016/j.jad.2018.02.051.
    • van de Grift, TC, Elaut E, Cerwenka SC, et al. Effects of medical interventions on gender dysphoria and body image. Psychosom Med. 2017;79(7):815-823. doi:10.1097/PSY.0000000000000465.
    • Dhejne C, Van Vlerken R, Heylens G, Arcelus J. Mental health and gender dysphoria: A review of the literature. Int Rev Psychiatry. 2016;28(1):44-57. doi:10.3109/09540261.2015.1115753.
    • Wilson EC, Chen YH, Arayasirikul S, Wenzel C, Raymond HF. Connecting the dots: Examining transgender women’s utilization of transition-related medical care and associations with mental health, substance use, and HIV. J Urban Health. 2015;92(1):182-192. doi:10.1007/s11524-014-9921-4.
    • de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4):696-704. doi:10.1542/peds.2013-2958.
    • Davis SA, Colton Meier S. Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female-to-male transgender people. Int J Sex Health. 2014;26(2):113-128. doi: 10.1080/19317611.2013.833152.
    • Byne W, Bradley SJ, Coleman E, et al. Report of the American Psychiatric Association task force on treatment of gender identity disorder. Arch Sex Behav. 2012;41(4):759-796. doi:10.1007/s10508-012-9975-x.
    • Murad MH, Elamin MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, Montori VM. Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol (Oxf). 2010;72(2):214-31. doi:10.1111/j.1365-2265.2009.03625.x.
       
  • Examples of published medical studies on hormone-replacement therapy:
    • White Hughto JM, Reisner SL. A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgend Health. 2016;1(1):21-31. doi:10.1089/trgh.2015.0008.
    • Bouman WP, Claes L, Marshall E, et al. Sociodemographic variables, clinical features, and the role of preassessment cross-sex hormones in older trans people. J Sex Med. 2016;13(4):711-719. doi:10.1016/j.jsxm.2016.01.009..
    • Costa R, Colizzi M. The effect of cross-sex hormonal treatment on gender dysphoria individuals’ mental health: A systematic review. Neuropsychiatr Dis Treat. 2016;12:1953-1966. doi:10.2147/NDT.S95310.
    • Colizzi M, Costa R, Todarello O. Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: Results from a longitudinal study. Psychoneuroendocrinology. 2014;39(1):65-73. doi:10.1016/j.psyneuen.2013.09.029.
    • Gorin-Lazard A, Baumstarck K, Boyer L, et al. Hormonal therapy is associated with better self-esteem, mood, and quality of life in transsexuals. J Nerv Ment Dis. 2013;201(11):996-1000. doi:10.1097/NMD.0000000000000046.
    • Colizzi M, Costa R, Pace V, Todarello O. Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style. J Sex Med. 2013;10(12):3049-3058. doi:10.1111/jsm.12155.
       
  • Examples of published medical studies on surgeries:
    • General studies on health after surgery:
      • van de Grift, TC, Elaut E, Cerwenka SC, Cohen-Kettenis PT, Kreukels, BP. Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study. J Sex Marital Ther. 2018;44(2):138-148. doi:10.1080/0092623X.2017.1326190.
      • Castellano E, Crespi C, Dell’Aquila C, et al. Quality of life and hormones after sex reassignment surgery. J Endocrinol Invest. 2015;38(12):1373-1381. doi:10.1007/s40618-015-0398-0.
         
    • Breast reconstruction
      • Weigert R, Frison E, Sessiecq Q, Al Mutairi K, Casoli V. Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals. Plast Reconstr Surg. 2013;132(6):1421-1429. doi:10.1097/01.prs.0000434415.70711.49.
         
    • Bilateral mastectomy and chest reconstruction:
      • Berry MG, Curtis R, Davies D. Female-to-male transgender chest reconstruction: A large consecutive, single-surgeon experience. J Plast Reconstr Aesthet Surg. 2012;65(6):711-719. doi:10.1016/j.bjps.2011.11.053.
      • Ott J, van Trotsenburg M, Kaufmann U, et al. Combined hysterectomy/salpingo-oophorectomy and mastectomy is a safe and valuable procedure for female-to-male transsexuals. J Sex Med. 2010;7(6):2130-2138. doi:10.1111/j.1743-6109.2010.01719.x.
      • Richards C, Barrett J. The case for bilateral mastectomy and male chest contouring for the female-to-male transsexual. Ann R Coll Surg Engl. 2013;95(2):93-95. doi:10.1308.003588413X13511609957290.
         
    • Phalloplasty, metoidioplasty:
      • Wierckx K, Van Caenegem E, Elaut E, et al. Quality of life and sexual health after sex reassignment surgery in transsexual men. J Sex Med. 2011;8(12):3379-3388. doi:10.1111/j.1743-6109.2011.02348.x.
         
    • Vaginoplasty
      • Papdopulos, NA, Lellé, JD, Zavlin, D, et al. Quality of life and patient satisfaction following male to female sex reassignment surgery. J Sex Med. 2017;14(5):721-730. doi:10.1016/j.jsxm.2017.01.022.
      • Da Silva, DC, Schwarz, K, Fontanari, AM, et al. WHOQOL-100 before and after sex reassignment surgery in Brazilian male-to-female transsexual individuals. J Sex Med. 2016;13(6):988-993. doi:10.1016/j.jsxm.2016.03.370.
      • Zavlin, D, Schaff, J, Lellé, JD, et al. Male-to-female sex reassignment surgery using the combined vaginoplasty technique: satisfaction of transgender patients with aesthetic, functional, and sexual outcomes. Aesthetic Plast Surg. 2018;42(1):178-187. doi:10.1007/s00266-017-1003-z.
      • Lobato MI, Koff WJ, Manenti C, et al. Follow-up of sex reassignment surgery in transsexuals: a Brazilian cohort. Arch Sex Behav. 2006;35(6):711-715. doi:10:1007/s10508-006-8074-y.
         
    • Facial Feminization Surgery:
      • Ainsworth TA, Spiegel JH. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Qual Life Res. 2010;19(7):1019-1024. doi:10.1007/s11136-010-9668-7.
      • Spiegel JH. Facial determinants of female gender and feminizing forehead cranioplasty. Laryngoscope. 2011;121(2):250-261. doi:10.1002/lary.21187.
      • van de Ven B. Facial feminisation, why and how? Sexologies. 2008;17(4):291-298. doi:10.1016/j.sexol.2008.08.008.
      • Noureai SR, Randhawa P, Andrews PJ, Saleh HA. The role of nasal feminization rhinoplasty in male-to-female gender reassignment. Arch Facial Plast Surg. 2007;9(5):318-320. doi:10.1001/archfaci.9.5.318.
      • doi:10.1097/QAI.0b013e3181fbc9ec.
      • Satterwhite, T, Morrison, SD, Ludwig, DC, et al. Abstract: Prospective quality of life outcomes after facial feminization surgery. Plast Reconstr Surg Glob Open. 2017;5(9 Suppl.):204-205. doi:10.1097/01.GOX.0000526461.64463.ce.
      • Berli, JU, Capitán, L, Simon, D, Bluebond-Langner, R, Plemons, E, Morrison, SD. Facial gender confirmation surgery—review of the literature and recommendations for Version 8 of the WPATH Standards Of CareInt J Transgenderism. 2017;18(3), 264-270. doi:10.1080/15532739.2017.1302862.

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