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

Abstract

Breast and chest reconstructions are commonly performed gender-affirming operations in the transgender and gender-expansive population. For both masculinizing and feminizing reconstructions, a number of additional procedures, such as lipocontouring of the trunk and chest, reconstruction of the nipple, and associated secondary repair operations, are medically indicated for resolution of gender dysphoria. However, insurance coverage for chest/breast surgery and additional procedures is often limited. Previous studies have noted that coverage guidelines may contain medically unsupported and discriminatory coding guidelines for masculinizing chest reconstruction, especially for additional procedures such as nipple reconstruction.1,2 Coverage of feminizing breast reconstruction as a gender-affirming procedure is often limited and has not been quantified. For both masculinizing and feminizing chest/breast surgery, coverage of additional lipocontouring procedures has not been explored. This report includes a quantitative analysis of variation in coverage for chest- and breast-related gender-affirming operations according to standardized CPT codes and coverage descriptions. Best practice guidelines for coding coverage were formulated based on the senior authors’ (E.I.Y. and A. H.) legal and clinical expertise, respectively. A convenience sample of insurers’ medical coverage policies for gender-affirming breast and chest reconstruction was reviewed.3 Plans without CPT codes covered and duplicate policy texts were excluded. The remaining plans (n = 53) were analyzed for positive, negative, indeterminate, or unwritten coverage of CPT codes applying to masculinizing chest reconstruction, feminizing breast reconstruction, and additional procedures used in both operations such as nipple reconstruction and lipocontouring. Coverage of CPT codes for masculinizing chest reconstruction was inconsistent, with universal coverage for only one code (i.e., 19304) (Fig. 1). The most consistently covered codes were for mastectomy. Medically necessary additional procedures for chest masculinization, including nipple reconstruction and lipocontouring, were frequently listed as noncovered codes. There was not universal coverage for feminizing breast reconstruction in plans covering masculinizing chest reconstruction, with only 71.7 percent of policy texts indicating some coverage.Fig. 1.: Coverage status for breast and chest reconstruction procedures. Insurance coverage status for 53 insurance plans is listed for a number of gender-affirming procedures of the chest and breast, coded as either positive, negative, unwritten, or indeterminate.The exclusion of specific CPT codes, frequently without clinical rationale, is medically unsupported. In addition, this practice is discriminatory, conflicts with established legal precedent, and may discourage surgeons from performing medically necessary procedures and significantly delay care for transgender and gender-expansive patients. Further advocacy is needed to protect patients and surgeons from medically unsupported denials of care. Lack of consistent, clinically sound insurance coverage for medically necessary gender-affirming procedures limits the quality of surgical care provided to transgender patients, who already face considerable health disparities. Lack of coverage forces patients and surgeons to delay care or creates significant burden to patients. The authors’ proposed coding coverage best practices (Table 1) serve as a guideline and rationale for appropriate CPT code use in gender-affirming breast and chest reconstruction.4 Ideal coding is provided for breast and chest reconstruction, nipple reconstruction, and associated lipocontouring procedures. However, additional procedures and their corresponding codes may be medically necessary to provide appropriate reconstruction in individual clinical presentations. Table 1. - Gender-Affirming Breast and Chest Reconstruction CPT Coding Best Practices Procedure CPT Code Description Rationale Breast and chest reconstruction 19303–19304 Mastectomy, simple, complete; mastectomy, subcutaneous Masculinizing chest reconstruction 19318 Reduction mammaplasty Breast or chest reconstruction in patients with nonbinary gender goals 19325 Mammaplasty, augmentation; with prosthetic implant Feminizing breast reconstruction Nipple-areola complex reconstruction 11920–11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation Nipple reconstruction when natal tissue retention is not appropriate, or when nipple appearance is incomplete after reconstruction 19350 Nipple-areola reconstruction Free or pedicled nipple graft concurrent with chest or breast reconstruction 15200 Full-thickness graft, free Nipple reconstruction using extraneous chest skin rather than natal nipple graft Lipocontouring 15877 Suction-assisted lipectomy; trunk Reduction of trunk adipose distribution that would cause dog-ear or other significant contour irregularity 20926 Tissue grafts, other Addition of adipose tissue for breast reconstruction and during repair for contour irregularities DISCLOSURE The authors have no relevant financial disclosures to report.