An Introduction to Insurance Denial For Top Surgery

Even though Dr. Mosser uses the informed consent model, you’ll need a support letter from a therapist in order to get your top surgery approved. Once you have your support letter getting insurance approval for gender affirming surgeries can exhausting, but not impossible. Dr. Mosser has an insurance advocacy team who’s responsible for getting your top surgery approved whether he’s in network or out. Although the insurance advocacy team has a 90% success rate in getting future patients approved, there are denials.

In order to understand top surgery insurance denial and approval you’ll first need to understand that if an insurance company denies your top surgery, they’re denying the billing codes(s) associated with top surgery. It’s possible that one billing code may be approved and the other not. Such is the case with free nipple grafts which we’ll get into a little later.

How Gender Affirming Top Surgeries Are Coded

Medical coding is much like a translation and universal language between providers and insurance companies. It’s a medical coder’s job to take something written one way by a provider and translate it as accurately as possible into a numeric or alphanumeric code. With gender affirming surgeries, there are much fewer codes so this information covered here will be easy to digest.

FTM/N top surgery is coded as a Breast Mastectomy. ‘Traditionally’ a Breast Mastectomy is sometimes performed when a cisgender woman or trans/non-binary identified person who was assigned female at birth develops breast cancer and the doctor mandates this surgical procedure should be done. There are no transgender billing codes at this time, so this is why an FTM/N top surgery is coded as a Breast Mastectomy. For gender affirming surgeries CPT codes are used to code your surgery. CPT code stands for ‘Current Procedure Terminology’.

Breast Mastectomy CPT billing code: 19303-50-22

Free Nipple Graft (nipple removal and relocation) CPT billing code: 15200

MTF/N top surgery is coded as a cosmetic breast augmentation.

Breast Augmentation CPT billing code: 19325

It’s almost as simple as it sounds, medical billers take information from the medical coder and make a bill for the insurance company (called a ‘claim’). The biller then sends this ‘claim’ and figures out how much of the bill the patient owes, after insurance is taken out.

The medical biller acts as a waypoint between patients, healthcare providers and insurance companies.

 What Happens When a Top Surgery Billing Code Is Denied

Once your ‘claim’ is submitted the insurance companies will come back with either an ‘approval’ or a ‘denial’ of specific CPT billing codes. Meaning if your surgery has more than one CPT billing code (such as FTM/N top surgery) then they could approve one, but deny the other.

Recently with health insurance companies like Aetna and United Health Care they may approve the Breast Mastectomy CPT code of 19303 but deny the Free Nipple Graft CPT code of 15200 or the Nipple Areolar Reconstruction CPT billing code of 19350. Insurance companies see getting free nipple grafts procedure as ‘cosmetic’ and due to this unfortunate decision by certain insurance companies we would be forced to collect the fees pertaining to this portion of your surgery

When Your ‘Free Nipple Graft’ Code Gets Denied

Currently we’ve only seen the denial of the Free Nipple Graft code with the insurance companies Aetna and United Health Care. We hope that other insurance companies don’t follow suit. At the Gender Confirmation Center we believe that the patient should have the choice of whether or not to retain their nipples and believe it should be covered by insurance if they choose to keep them.

If your Free Nipple Graft CPT billing code gets denied you should do the following if you’re able to:

  1.   Appeal the claim. You have the opportunity to ‘fight’ the insurance company
  2.   Call your insurance company and let them know why retaining your nipples and having them covered by insurance is important

If your insurance continues to deny your appeal and it’s looking like you’ll need to pay for your Free Nipple Grafts out of pocket then please read the following.

Dr. Mosser’s Stance on Free Nipple Graft Insurance Denials

Dr. Mosser’s continued surgical work and communication with the transgender, non-binary and gender expansive community has given him a greater understanding on how impactful surgery can be in finding congruence in one’s gender. This is why Dr. Mosser and his team are very disheartened on the stance that Aetna and United Healthcare has taken on denying Free Nipple Grafts. Although some folks opt for no nipples there are a lot of folks who want to keep theirs and this decision should be supported by insurance companies.

What Do I Do When My ‘Free Nipple Graft’ Billing Code Gets Denied?

Anytime a surgeon cuts into a patient there is a code and a fee for it. If your insurance denies your free nipple graft billing code than you will be responsible for paying for the nipples out of pocket (unless you opt for no nipples at all). If you opt for ‘no nipples’ but still want the appearance of nipples there are 3D nipple tattooing options. If you want to retain your nipples and have to pay out of pocket you’ll want to understand why paying for the Free Nipple Graft (nipple reconstruction) is expensive.

The Cost of Free Nipple Grafts When Paying Out of Pocket

When you think of the size of your chest compared to the size of your nipples you would think the billing code related to a ‘smaller’ part of your body would be less expensive. This logic may arise if you’re thinking ‘smaller’ means ‘less’ work. However, Nipple Reconstruction (Free Nipple Grafts) is a detailed process no matter what type of FTM/N top surgery you’re having.

The price you’d be responsible for paying out of pocket (if you’re denied) is the contracted price with the insurance company you have. Meaning, you pay what your insurance company would normally pay (if they had agreed to cover the billing code).

FTM/N Top Surgery Procedures That Don’t Have a ‘Free Nipple Graft’ CPT Code

Unless you are opting for an FTM/N top surgery with no nipples there will always be a ‘nipple reconstruction fee’. This is because when performing any type of FTM/N top surgery the nipple is being ‘reconstructed’ in some way. So, a nipple reconstruction fee is associated with the following procedure types: