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An Introduction to Insurance Denial For Top Surgery

Even though our surgeons uses the informed consent model, if you want to try to get insurance coverage, you’ll need a support letter from a therapist. Once you have your support letter, getting insurance approval for gender affirming surgeries can be exhausting, but not impossible. The Gender Confirmation Center has an insurance advocacy team who’s responsible for getting your top surgery approved whether or not we are in network. Although the insurance advocacy team has a 90% success rate in getting future patients approved, insurance denials still happen.

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 translated universal language used by providers and insurance companies through the use of CPT (or current procedure terminology) codes. It’s a medical coder’s job to take something written by a provider and translate it as accurately as possible into a numeric or alphanumeric code. With gender affirming surgeries, there are fewer codes, so the information covered here will be easy to digest.

Since there are no billing codes specific for transgender patients at this time,  top surgery is coded as a “breast mastectomy”. This is also the procedure code that is used when a cisgender woman or trans/non-binary identified person assigned female at birth develops breast cancer that requires a mastectomy to be performed. Additionally, breast augmentations are coded as cosmetic procedures.

The following CPT codes are used for gender-affirming top surgery:

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. In other words, if your surgery has more than one CPT billing code (such as FTM/N top surgery and a free nipple graft) your insurance company could approve one, but deny the other.

For example, health insurance companies like Aetna and United Health Care 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. Unfortunately, some insurance companies see getting free nipple grafts procedure as ‘cosmetic,’ and because of this, we would be forced to collect the fees pertaining to this portion of surgery.

When Your ‘Free Nipple Graft’ Code Gets Denied

Currently, we’ve only seen the denial of the Free Nipple Graft code with 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 we believe it should be covered by insurance if they choose to. If your Free Nipple Graft CPT billing code gets denied, you should do the following if you’re able to:

  • Appeal the claim. You have the opportunity to ‘fight’ the insurance company.
  • 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, please read the following:

Our Stance on Free Nipple Graft Insurance Denials

Dr. Mosser’s continued surgical work and communication with the trans, 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 our practice is very disheartened by the stance that Aetna and United Healthcare have taken by denying free nipple graft procedures. Although some folks opt for an end result with no nipples, there are a lot of folks who want to keep their nipples, and this decision should be supported by insurance companies. Nipple areolar complex (NAC) reconstruction can be an integral component of chest reconstruction in the treatment of transgender and gender diverse people. Dr. Mosser and other surgeons published this article in an effort to spread awareness around the importance of insurance companies covering free nipple grafts.

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

Anytime a physician performs surgery, there is a billing code and fee attached. If your insurance denies your free nipple graft billing code, you will be responsible for paying for nipple reconstruction 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, read below to learn about why paying for the Free Nipple Graft 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 might 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 is an extremely detailed process.

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 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. Nipple reconstruction fees are associated with the following procedure types:

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