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

Last year, Tim Chevalier received his first refusal from his insurance company for the hair removal he needed as part of his penis aesthetics, i.e. penis creation.

Electrolysis is a common procedure among transgender people like 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 required for phalloplasty or vaginoplasty, that is, the creation of the vagina, because all the hair must be removed from the tissues that will be transferred during surgery.

Chevalier’s insurer, Anthem Blue Cross, told him he needed what’s known as prior authorization for the procedure. Even after Chevalier obtained the mandate, he said, his reimbursement claims continued to be denied. According to Chevalier, Anthem said the procedure is cosmetic.

Many trans patients have difficulty getting their insurance companies to cover gender confirmation care. One reason is transphobia within the US health care system, but the other has to do with how insurance companies code medical diagnoses and procedures. Nationally, health care providers use a list of diagnostic codes provided by the International Classification of Diseases, 10th revision, or ICD-10. Transgender advocates say many of these did not meet the needs of patients. These diagnostic codes provide the basis for determining which procedures will be covered by insurance, such as electrolysis or surgery.

Dr. said.

Joanna Olson Kennedy

Medical Director of

Trans Youth Center for Health and Development

At Children’s Hospital Los Angeles.

It calls for a transition to the 11th version of the coding system, which was endorsed by the World Health Organization in 2019 and whose worldwide adoption began in February. Today, more than

34 countries use the ICD-11


Her new edition

Replace obsolete terms

Such as “sex change” and “gender identity disorder” with “gender incongruity”, which is no longer classified as a mental health condition, but as a sexual health condition. Olson Kennedy said this is critical in reducing the stigmatization of transgender people in health care.

Moving away from a mental health rating could also mean more coverage for gender confirmation care by insurance companies, which sometimes question mental health claims

More severe than those physical ailments

. WHO officials said they hope that adding the gender discrepancy to the sexual health chapter “helps increase access to care for health interventions” and “remove the stigma of the condition.”

According to the World Health Organization website


However, history indicates that the ICD-11 will likely not be implemented in the United States for years. The World Health Organization first endorsed ICD 10 in 1990, but the United States did not implement it for it

25 years


Meanwhile, patients who identify as transgender and their doctors spend hours trying to get coverage — or use crowdfunding to cover large out-of-pocket bills. Chevalier estimated that he received 78 hours of electrolysis at $140 an hour, at a cost of $10,920.

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

Tim Chevalier_07.jpg

Tim Chevalier, a software developer in Oakland, California, has been repeatedly rejected by his health plan over compensation claims for electrolysis hair removal needed for phalloplasty, the creation of a penis. His forearm shows where to remove hair to harvest his skin for surgery.

Shelby Knowles / Kaiser Health News

However, even after pre-approval, Anthem responded to Chevalier’s claims by saying that electrolysis would not be compensated because the procedure is considered cosmetic, not medically necessary. That’s regardless of Chevalier’s diagnosis of gender identity disorder—the psychological distress a person feels when one’s biological sex does not match one’s gender identity—which many clinicians consider a legitimate medical reason for hair removal.

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

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

Certain procedures received by trans patients may also be excluded from coverage because insurance companies consider them “gender-specific.” For example, a gynecologist’s visit to a transgender man may not be covered because his insurance plan only covers those visits for people who are registered as women.

“There’s always this question: What gender should you tell the insurance company?” said Dr. Nick Gorton, an emergency physician in Davis, California. Gorton, who is transgender, recommends that his patients with insurance plans that exclude transgender 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 transgender man becomes “What is more expensive — paying for testosterone or paying for a Pap smear?” – As insurance may not cover both.

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

A symbol for pelvic pain, unlike gender dysphoria

, in the patient’s billing record. Gorton said pelvic pain is a legitimate reason for surgery and is generally accepted by insurance companies. But some insurance companies backed down, and he was forced to find other ways to help his patients.

In 2005, California passed

The first law of its kind

which prohibits discrimination by health insurance on the basis of sex or gender identity. Now, 24 states and Washington, D.C., ban private insurance from

Excluding transgender health care benefits


Consequently, Gorton no longer needs to use different codes for patients seeking gender confirmation care at his California clinic. But doctors in other countries are still struggling.

When he said Dr.

Eric Menninger

internist and pediatrician at

The Gender Health Program at Indiana University

, treating a transgender child seeking hormone therapy, typically uses the ICD-10 code for “administering medication” as the main reason for patient visit. This is because Indiana does not have a law providing insurance protection for LGBTQ+ individuals, and when gender identity disorder is listed as the main cause, insurance companies decline coverage.

It’s frustrating,” Menninger said. On a patient’s billing history, he sometimes presents multiple diagnoses, including gender identity disorder, to increase the likelihood that the procedure will be covered. “It’s not usually hard to come up with five, seven or eight diagnoses for a person because there are a lot of ambiguous diagnoses out there.”

ICD-11 implementation will not fix all coding issues, as insurance companies may continue to refuse coverage for actions related to gender discrepancy even though it is listed as a sexual health condition. It also wouldn’t change the fact that many states still allow insurance to exclude sex confirmation care. But Olson Kennedy said that in terms of reducing stigma, this is a step forward.

One of the reasons it took the United States so long to switch to the ICD-10 is that the American Medical Association has strongly opposed the move. He argued that the new system would place an incredible burden on physicians. Physicians will “have to deal with 68,000 diagnostic codes — a fivefold increase from about 13,000 diagnostic codes in use today,” according to the AMA.

Written in a letter 2014

. The union argued that implementing a program to modernize providers’ coding systems would also be costly, and deal a financial blow to small medical practices.

Unlike previous coding systems, the ICD-11 is entirely electronic, with no physical evidence of codes, and can be integrated into a medical facility’s existing coding system without the need for a new offering, said Christian Lindmeier, a WHO spokesperson.

It is not yet clear whether these changes will make adoption of the new version easier in the United States. Currently, many trans patients who need gender confirmation 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 compensation, my payments were late, and it took a lot of my time,” Chevalier said. “Most people had just given up.”


(Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and survey, KHN is one of the three major drivers in


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

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