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U.S. Insurers Seldom Cover Gender-Affirming Voice and Facial Feminization Surgery

Key findings

  • This study systematically reviewed insurance coverage for gender-affirming otolaryngology treatments by the top three commercial insurers in each U.S. state (n=149 because the information was unobtainable from one company)
  • Only 3% of commercial insurers offered favorable policies for voice-related gender-affirming interventions and 18% for facial feminization surgery
  • 76% of companies explicitly excluded coverage for voice therapy/voice surgery and 68% excluded facial feminization surgery
  • Even when policies granted preauthorized or case-by-case coverage, medical necessity criteria were often unavailable, and the information available was inconsistent and often outside international standards of care

Lack of access to ancillary gender-affirming surgery is a persistent concern among transgender individuals. Coverage for genital and chest surgery is often available for patients who can meet precertification criteria. Still, other services affecting secondary sex characteristics are usually considered cosmetic, despite evidence of their benefits for psychosocial adaptation and quality of life.

In the field of otolaryngology, gender-affirming interventions include voice therapy/voice surgery and facial feminization surgery (FFS). David A. Shaye, MD, MPH, a facial plastic and reconstructive surgeon in the Department of Otolaryngology–Head and Neck Surgery at Mass Eye and Ear, Matthew R. Naunheim, MD, MBA, a laryngologist in that department, and colleagues recently confirmed U.S. insurance companies seldom cover these procedures.

They published their results in The Laryngoscope and Facial Plastic Surgery & Aesthetic Medicine. The full list of co-authors on both studies includes Elizabeth M. Banaszak, MA, CCC-SLP; Adeeb Derakhshan, MD; Elliana K. DeVore, MD; Shekhar K. Gadkaree, MD; Linda N. Lee, MD, FACS; Justin C. McCarty, DO; Kayla Richburg, MHA; Rahul Seth, MD; and Tiffany V. Wang, MD.


In April 2020, one of the authors conducted a web-based search for the three commercial insurance companies in each state with the highest enrollments in 2019. The company was contacted via telephone or email if policy information was unavailable online. Policies were reviewed for coverage of:

  • 7 voice-related interventions—open procedure to alter the voice, endoscopic procedure to alter the voice, behavioral voice evaluation, laryngeal function studies, laryngoscopy, individual voice therapy, and group voice therapy
  • 14 FFS procedures—rhinoplasty, forehead contouring, browlift, blepharoplasty, mandible shaping, chondrolaryngoplasty, cheek augmentation, facelift, liposuction, neck lift, hair transplant, lip enhancement, chin reduction, and otoplasty


One of the 150 companies was excluded from the analysis due to the inability to access any policy information. Of the 149 others:

  • Favorable coverage for at least one procedure—4 companies (3%) for laryngeal interventions and 27 companies for FFS (18%)
  • Case-by-case coverage—12 (8%) and 13 (9%)
  • Coverage explicitly excluded—113 (76%) and 101 (68%)
  • No policy—20 (13%) and 8 (5%)

Medical Necessity Criteria

Medical necessity criteria were often absent even when policies granted preauthorized or case-by-case coverage. What information was available was inconsistent, and it was often outside the standards of care of the World Professional Association for Transgender Health:

  • Laryngeal interventions—Of nine policies for which criteria could be determined, five required regular visits with a mental health provider and five required referral from a mental health professional
  • FFS—Of 26 policies, 19 required regular visits with a mental health provider and 18 required referral from a mental health professional

Ease of Obtaining Information

For each company examined, the researcher used a clinically validated usability questionnaire, the Single Ease Question, to rate the ease of abstracting policy information on a seven-point scale.

The average score was 6.05, representing a task completion rate of 80% on this instrument, indicating the information was rather difficult to obtain. For 20 companies (13%), it was necessary to call or send an email to determine policy information.

Multiple Barriers to Care

Despite established medical value and years of clinical experience, gender-affirming interventions within otolaryngology have yet to be fully considered by third-party payors. There are multiple barriers to care for individuals seeking to align their gender expression with their gender identity—not just the scarcity of insurance coverage but also limited access to information about coverage and its requirements.

of commercial U.S. insurers offer favorable policies for voice-related gender-affirming interventions

of commercial U.S. insurers offer favorable policies for gender-affirming facial feminization surgery

of commercial U.S. insurers exclude coverage for voice-related gender-affirming interventions

of commercial U.S. insurers exclude coverage for gender-affirming facial feminization surgery

Learn more about the Department of Otolaryngology–Head and Neck Surgery at Mass Eye and Ear

Refer a patient to Mass Eye and Ear/Mass General Brigham

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