Adolescent  Top Surgery

With strict criteria and a few extra steps in the process, Dr. Mosser will perform FTM/N top surgery on adolescents.  The term ‘adolescent’ refers to a person younger than 18, which is someone beneath the age of majority in the United States.  As a result, if persons under 18 need top surgery then there will  be certain steps to follow due to the patient being a minor.

Dr. Mosser’s Approach: The Difference Between Adolescent & Adult Top Surgery

In comparison to adults, WPATH’s Standards of Care 7 the adolescent qualifying criteria for top surgery is more involved due to the patient being under 18 years of age. It’s important to note that Dr. Mosser is a member of WPATH and is working towards helping develop guidelines for the upcoming Standards of Care 8. He has in-depth knowledge and perspective on trans spectrum youth and their decision to move forward with a gender affirming surgery.

It’s important to cover some core differences between adolescent cases and adult cases and Dr. Mosser’s approach to both of them:

Adolescent Cases

  1. 2 letters of support (one from an M.D such as a primary care physician & one from a therapist,  psychiatrist or psychologist)
  2. A scheduled call with the patient’s therapist, psychiatrist or psychologist
  3. All legal guardians sign a consent form
  4. Photographic release signed by all legal guardians
  5. Consent to treat a minor form
  6. In some cases, a minor case review is conducted by the hospital

Adult Cases

  1. No letters of support required (unless seeking insurance approval)
  2. No call with a a mental healthcare provider needed
  3. Photographic release signed by patient

Dr. Mosser’s Phone Call With The Adolescent’s Therapist, Psychiatrist or Psychologist

There will be a scheduled phone call between Dr. Mosser and the adolescent’s mental healthcare provider.  Clear communication around top surgery and the patients outside care team is essential in setting higher standards of care. The phone call provides an opportunity to discuss the patient’s mental health in addition to proactive approaches both healthcare providers can take in order to best care for the patient. The phone call with the mental healthcare provider will be scheduled after the consultation but before surgery is scheduled.

Adolescent Top Surgery Consultation

An adolescent would need a consultation with Dr. Mosser to determine if they are eligible for top surgery. At any given time, Dr. Mosser is commonly scheduled out for consults by 1-2 months. Summer, spring and holiday time slots fill up quickly.  Adolescents will need permission from all parents or all legal guardians to have a consultation with Dr. Mosser.

  • Legal guardianship for medical decision-making must be clear. If the parents are divorced, then a court paper will need to be produced with regards to who can make medical decisions on behalf of the adolescent
  • If one of the legal guardians is not part of the consultation, then a follow up phone meeting available to that guardian

Insurance Approval vs Out of Pocket

Insurance

Dr. Mosser accepts and works with a lot of insurance companies including some Medi-Cal plans. It’s important to note that some Medi-Cal patients have difficulty receiving an approval for a consultation and a referral may be necessary. If you’re seeking insurance approval for adolescent FTM/N top surgery then be prepared for a denial the first time around. It’s important to note that patients should appeal any insurance denials the receive, because MOST cases get overturned on appeal. The Gender Confirmation Center has an Insurance Advocacy Team to support you through this challenging process by equipping you with the resources to achieve a successful appeal.

Out of Pocket

If you’re going to be paying out of pocket than your wait time for getting surgery scheduled will decrease. Depending on the urgency of surgery some parents may opt to pay out of pocket to expedite the process, and (though it would be a more uncertain process) potentially even try to get insurance approval reimbursement after the case has already occurred.

Minor Case Review Process

Depending on what surgery center the insurance approves the adolescents top surgery at, an independent review of the patients case may be required. If this is the case than the surgery can’t be scheduled until Dr. Mosser has reviewed the minors case with each team member at the hospital. Although rare, the hospital could possibly delay or deny the adolescent from getting top surgery at their facility. The review process takes about 2-3 weeks and would require the following information from you:

  • 2 letters of support:
    • Mental Healthcare support letter: A letter of support is needed from a mental healthcare provider (therapist, psychiatrist or psychologist) in order for the adolescent to get top surgery with Dr. Mosser. If you do not have a mental healthcare provider for your child at this time, more information on finding one can be found here
    • MD support letter: The adolescent’s primary care physician will also need to provide a letter of support
  • Current list of medications (including dosage) and immunizations
  • Guardianship approval: Legal guardianship regarding medical decision-making has to be clear. In the event the parents are divorced then a court paper will need to be provided on who will make the medical decisions on behalf of the minor
  • Consent to treat minor form, health information sharing release form (with ability to release info with the therapist, psychiatrist or psychologist) and a photographic release form need to be signed and ready for case review. All signed by both legal guardians.

To limit delays it’s best to gather and organize any of the above documents now so they’re on hand if you need them.

Insurance Authorization Tips

Dr. Mosser’s Insurance Advocacy team has many years of experience in navigating insurance approval with different states and health plans. Here are some tips from the pros:

  • Get as many support letters as possible. Only 2 is required (one from a mental healthcare provider such as a therapist, psychiatrist or psychologist and one from a medical doctor such as a primary care physician), but more documented support is always a positive
  • Ensure the mental healthcare support letter & MD support letters emphasize parental (or legal guardian(s)) support
  • A letter dedicated specifically to the adolescent being on hormones from the MD is helpful, but not required. Please note that a statement of the adolescent being on hormones is required on the mental healthcare support letter
  • If the adolescent is wanting to change their name or gender marker it is best to have this completed before or after top surgery and not during the insurance authorization process
    • Dr. Mosser can easily provide documents for gender/name change after top surgery has taken place
  • If you are appealing an insurance denial then asking the adolescents team of providers for an additional letter that addresses the reason for appealing the denial can help significantly

Insurance Authorization Time Frames

The estimated top surgery timeline (from consultation to surgery) for minors is usually between 4 and 6 months. Staying positive during the insurance approval process is very helpful and meeting with a trained mental health gender specialist for consultation and support can be very helpful during the waiting period. If urgency of surgery is a factor (the adolescent is starting a new school, on summer break etc.) being prepared to pay out of pocket is helpful.

Insurance authorization for an adolescent FTM/N top surgery is the most variable part of the process, and we have seen it take anywhere from 2 weeks – 1 year. Below is a breakdown of that time frame:

  • Insurance denies minors frequently during the initial review (but patients should always appeal because most cases get overturned). Some of the most common reasons for a denial are:
    • Age: The insurance company denies coverage because the patient is a minor
    • Hormone therapy: The insurance company denies coverage because the patient has not yet been receiving hormone therapy or has not been receiving treatment for a long enough period
    • Talk/evaluative therapy: The insurance company requires that the patient demonstrate being enrolled in ongoing psychotherapy
  • Appealing a denial can take 1-3 months
    • If you need help appealing or need advice on the denial notice you received please Google transfamilysos.org, since they provide free assistance in helping you through the appeals process
    • Appealing a denial doesn’t guarantee an approval, but it does help insurance companies rethink their policies. As a general rule, please note that we have seen higher insurance authorizations rates for minors with Anthem Blue Cross

Post-Surgery Restrictions: Recovering From Adolescent FTM/N Top Surgery

The top surgery recovery period and activity restrictions for an adolescent isn’t much different from an adult. Some adolescents may heal quicker and ‘bounce back’ after surgery quicker than an adult. Here’s a video of Dr. Mosser explaining movement after top surgery and  below are the activity restrictions:

  • 1-3 weeks: Patient cannot lift/carry more than 5 lbs
  • 3-6 weeks: Patient cannot lift/carry more than 25 lbs
  • 6 weeks-6 months: Patient can resume all normal activity except raising their arms at the shoulder level and above

In Conclusion

Stay positive, Dr. Mosser has performed FTM/N top surgery on many patients under 18 who were able to secure their surgery using insurance. The process may seem daunting at first, but you will have continued support from our office through the process. Here are some highlights from this content:

  • Dr. Mosser performs top surgery on patients under 18
  • You’ll need 2 letters of support, 1 from a mental healthcare provider and the other from a medical doctor. This is a requirement regardless of whether you are going through insurance or paying cash
  • Plan ahead, Dr. Mosser’s consultation wait times are booked out 1-3 months in advance
  • Insurance authorization for adolescent FTM/N top surgery has it’s challenges & requires extra effort but we have seen many approvals
  • Insurance denial for a minor’s top surgery is common. In most cases, appealing the denial will result in an approval. The appealing process takes 1-3 months
  • Insurance authorization can take anywhere from 2 weeks-1 year
  • If you want top surgery during the spring, summer or holidays keep in mind these slots fill up quickly
  • Dr. Mosser’s team will help you strategize insurance approval/denial, surgery scheduling and providing documents necessary to facilitate a smooth gender transition/alignment

San Francisco Bay Area Resources

  • Stanford Pediatric and Adolescent Gender Clinic :  Medical services for gender nonconforming youths and their families in one central location. The expert members of the Gender Clinic team consists of providers from pediatric endocrinology, adolescent medicine, pediatric urology and social services, supporting each child’s or adolescent’s gender identity. Services include help with social, medical and legal transitions. In addition to the core providers, adolescent gynecology, child and adolescent psychiatry, primary care and fertility preservation. All providers at the clinic are members of the World Professional Association for Transgender Healthcare (WPATH)
  • Department of Managed Health Care : This may be helpful for transgender patients seeking coverage for their gender affirming surgeries who have denied by their insurance and need to file a grievance (for California residents only)
  • SF LGBT Center : Provides a variety of LGBT community programming, employment services, & LGBT youth specific program
  • Gender Spectrum : Helps to create gender sensitive and inclusive environments for teens
  • Gender Health SF : SF Department of Public Health department that connects medi-cal recipients with gender affirming surgeries
  • PFLAG SF : Provides support for families of LGBT children
  • Lyon Martin : Trans Health Clinic providing hormonal replacement therapy and other services
  • Trans Care UCSF : A good site to look at in terms of gender affirming providers and services
  • The Pacific Center : The oldest LGBTQ center in the Bay Area, the third oldest in the nation and operates the only sliding scale mental health clinic for LGBTQ people and their families in Alameda County

National Resources

Additional Resources