HomeHealthHealth CareMedical coding creates barriers to care for transgender patients - Duluth News...

Medical coding creates barriers to care for transgender patients – Duluth News Tribune

Last year, Tim Chevalier received the first of many denials of coverage from his insurance company for the hair removal procedure he needed as part of a phalloplasty, to create a penis.

Electrolysis is a common procedure among transgender people such as Chevalier, a software developer in Oakland, California. In some cases, it is used to remove unwanted hair from the face or body. But it is also necessary for a phalloplasty or a vaginoplasty, the creation of a vagina, because all the hair must be removed from the tissue that is moved during the surgery.

Chevalier’s insurer, Anthem Blue Cross, told him that he would need a so-called pre-approval for the procedure. Even after Chevalier was cleared, he said, his refund claims were still denied. According to Chevalier, Anthem said the procedure was considered cosmetic.

Many trans patients struggle to get their health insurance company to cover gender-affirming care. One reason is transphobia within the US health care system, but another is how medical diagnoses and procedures are coded for insurance companies. Nationally, health care providers use a list of diagnostic codes provided by the International Classification of Diseases, Tenth Revision, or ICD-10. And many of them, say transgender advocates, don’t meet the needs of patients. Such diagnostic codes are the basis for determining which procedures, such as electrolysis or surgery, are covered by insurance.

“It is widely believed that the codes in ICD-10 are very limited,” says Dr.

Johanna Olson-Kennedy

medical director of the

Center for Trans-Youth Health and Development

at the Children’s Hospital in Los Angeles.

She advocates a move to the 11th edition of the coding system, which was approved by the World Health Organization in 2019 and rolled out around the world in February. Today more than

34 countries use ICD-11


The new edition has

replace obsolete terms

such as “transsexuality” and “gender identity disorder” with “gender mismatch”, which is no longer classified as a mental illness, but as a sexual health condition. This is crucial to reduce the stigma of transgender people in healthcare, Olson-Kennedy says.

A shift in mental health classification could also mean increased coverage of gender-affirming care by insurance companies, which sometimes question mental health claims.

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stricter than those for physical illnesses

. WHO officials have said they hope adding gender incongruity to a chapter on sexual health will “help increase access to care for health interventions” and “destigmatize the condition.”

according to the WHO website


However, history suggests that ICD-11 probably won’t be implemented in the US for years. The WHO first approved ICD-10 in 1990, but the US did not implement it before

25 years


Meanwhile, patients who identify as transgender and their doctors spend hours trying to get coverage — or use crowdfunding to cover large cash bills. Chevalier estimates that he received 78 hours of electrolysis at $140 per hour, which costs $10,920.

Anthem spokesperson Michael Bowman wrote in an email that “there has been no medical denial or denial of coverage” because Anthem “pre-approved coverage for these services.”

Tim Chevalier, a software developer in Oakland, California, has faced repeated refusals from his health plan for reimbursement claims for the electrolysis hair removal required for his phalloplasty to create a penis. His forearm shows where hair was removed to harvest his skin for surgery.

Shelby Knowles / Kaiser Health News

But even after the pre-approval was given, Anthem responded to Chevalier’s claims by stating that the electrolysis would not be reimbursed because the procedure is considered cosmetic and not medically necessary. This is separate from Chevalier’s diagnosis of gender dysphoria — the psychological distress felt when a person’s biological sex and gender identity don’t match — which many doctors view as a medically legitimate reason for hair removal.

Bowman wrote that “after this issue was identified, Anthem implemented an internal process that included a manual override in the billing system.”

Still, Chevalier filed a complaint with the California Department of Managed Health Care, and the state declared Anthem Blue Cross inconsistent. Additionally, after KHN began asking Anthem questions about Chevalier’s accounts, two claims were resolved in July that had not been addressed since April. So far, Anthem Chevalier has paid back about $8,000.

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Some procedures trans patients undergo may also be excluded from coverage because insurance companies consider them “gender specific.” For example, a transgender man’s gynecological visit may not be covered because his insurance plan only covers those visits for people who are enrolled as women.

“There’s always the question: What gender should you tell the insurance company?” said Dr. Nick Gorton, an emergency medicine physician in Davis, California. Gorton, who is trans, recommends that his patients with insurance plans that exclude trans care calculate the out-of-pocket costs that would be required for certain procedures based on whether the patient lists themselves as male or female on their insurance papers. For example, Gorton said the question for a trans man becomes “which is more expensive – pay for testosterone or pay for a Pap smear?” – since insurance probably won’t cover both.

For years, some doctors have helped trans patients gain coverage by finding other medical reasons for their trans-related care. Gorton said that if, for example, a transgender man wanted a hysterectomy but his insurance didn’t cover gender-affirming care, Gorton would participate in the ICD-10

code for pelvic pain as opposed to gender dysphoria

, in the patient’s billing record. Pelvic pain is a legitimate reason for the surgery and is widely accepted by insurance companies, Gorton said. But some insurance companies withdrew and he had to find other ways to help his patients.

In 2005, California passed a

the first of its kind law

that prohibits discrimination by health insurers on the basis of sex or gender identity. Now 24 states and Washington DC ban private insurance from

excluding transgender-related health care benefits


As a result, Gorton no longer has to use different codes for patients seeking gender-affirming care in his California practice. But doctors in other states are still struggling.

When Dr.

Eric Meininger

internist and pediatrician at

Indiana University Health’s Gender Health Program

, treating a trans child seeking hormone therapy, he often uses the ICD-10 code for “medication management” as the main reason for the patient’s visit. That’s because Indiana doesn’t have a law providing insurance protection for LGBTQ+ people, and when gender dysphoria is listed as the main reason, insurance companies have denied coverage.

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“It’s frustrating,” Meininger said. In a patient’s billing file, he sometimes gives multiple diagnoses, including gender dysphoria, to increase the likelihood that a procedure will be covered. “It’s usually not hard to come up with five, seven or eight diagnoses for someone because there are a lot of vague ones.”

Implementing ICD-11 does not solve all coding problems, as insurance companies can still refuse to cover procedures related to gender incongruity even if it is listed as a sexual health condition. Nor will it change the fact that many states still allow insurance policies to exclude gender-affirming care. But in terms of reducing stigma, it’s a step forward, Olson-Kennedy said.

One of the reasons it took the US so long to switch to ICD-10 is that the American Medical Association strongly opposed the move. He argued that the new system would pose an incredible burden to doctors. Doctors would have to “battle with 68,000 diagnosis codes — a five-fold increase from the approximately 13,000 diagnosis codes currently in use,” the AMA

wrote in a letter from 2014

. Implementing software to update providers’ coding systems would also be costly, and deal a financial blow to small medical practices, the association argued.

Unlike previous coding systems, ICD-11 is completely electronic, with no physical manual of codes, and can be incorporated into a medical facility’s current coding system without the need for a new rollout, said Christian Lindmeier, a WHO spokesperson.

Whether these changes will facilitate adoption of the new edition in the US remains to be seen. For now, many trans patients in need of gender-affirming care have to pay their bills out of pocket, fight their insurance company for coverage, or rely on the generosity of others.

“Even though I did eventually get a refund, the refunds were delayed and it took a lot of my time,” Chevalier said. “Most people would have just given up.”


(Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Together with Policy Analysis and Polling, KHN is one of the three most important operational programs on


(Kaiser Family Foundation). KFF is an endowed non-profit organization that provides information on health issues to the nation.



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