Insurance coverage for hair removal procedures in the treatment of gender dysphoria

The World Professional Association for Transgender Health (WPATH) affirmed in 2008 and 2016 that laser hair removal and electrolysis are medically necessary to treat gender dysphoria.¹ Dermatologists and other qualified providers play an important role in the care of transgender patients by providing laser hair removal and/or electrolysis. These procedures can help alleviate gender dysphoria by preparing skin grafts preoperatively for gender-affirming genital surgeries and by removing distressing secondary sex characteristics, such as facial hair in transgender women. Anecdotally, coverage policies for hair removal therapies across insurance carriers vary widely, and many policies exclude such procedures as “cosmetic,” regardless of indication. To determine the availability of coverage for hair removal procedures, we examined the clinical policy bulletins for insurance carriers related to gender dysphoria.

This study did not constitute human subjects research and institutional review board oversight is not required. We examined the clinical policy bulletins related to the treatment of gender dysphoria of insurance carriers for explicit provisions related to laser hair removal or electrolysis as of October 1, 2018. We reviewed a list of 101 U.S. health insurance carriers named by Transcend Legal, a legal organization which helps transgender patients navigate health insurance options.² Transcend Legal attempted to create a list of major insurance companies in order to aid transgender patients in policy selection. Among 101 insurance carriers listed, 89 clinical policy bulletins were openly available for review as of October 2018. We analyzed policies based on hair removal procedure coverage for the following features: 1) broad cosmetic exclusion for hair removal therapy without explicit consideration of medical indications, 2) coverage for preparation of skin flaps or grafts for gender-affirming surgeries, 3) coverage for facial hair removal, 4) coverage for unspecified medical indications.

Forty-two (47%) carriers had broad cosmetic exclusions for hair removal therapies (Figure 1). Thirty-six (40%) carriers covered skin flaps or graft hair removal and eleven (12%) carriers covered facial hair removal when medical necessity criteria were met. Ten (11%) carriers would consider coverage via a medical necessity appeal, but do not explicitly provide coverage for the indication of gender dysphoria. Specific coverage details were listed in Supplemental Table 1.

Figure 1.

Insurance coverage for hair removal for the treatment of gender dysphoria in 89 policy bulletins.

Note: The percentages do not add up to 100% since policies may contain coverage language for 1 or more indication.

Dermatologists – as well as other qualified laser providers and electrologists – can provide safe and efficacious hair removal treatments to improve quality of life of transgender patients by treating gender dysphoria. Transgender women reported unwanted facial hair as a significant cause of body dissatisfaction and gender dysphoria.³ The use of hair-bearing skin flaps or grafts for gender-affirming genital surgery can result in urinary obstruction, incontinence, infection, and decreased patient satisfaction.⁴ While a plurality of insurance policy bulletins still contained broad exclusionary language on hair removal, a substantial proportion covered preoperative hair removal for gender-affirming surgeries or gender-affirming facial hair removal or both.

As gender-affirming surgical procedures are increasingly performed and covered by health insurance policies,⁵ the medical necessity and value of procedures beyond genital surgeries – including dermatologic procedures such as hair removal – are increasingly recognized. Dermatologists should lend our expertise in optimizing laser hair removal treatment protocols, particularly for the preparation of skin graft donor sites for vaginoplasty or phalloplasty.⁴ Dermatologists should also advocate for the creation of procedural code from the American Medical Association to facilitate reimbursement for medically necessary laser hair removal, as no such code currently exists. In contrast, Current Procedural Terminology code 17380 exists for electrolysis. Education for transgender patients regarding treatment options, efficacy and safety will also be required. Our study was limited to insurance carriers suggested by a Transcend Legal and may not necessarily be generalizable to all U.S. insurance plans. Ad hoc coverage from insurance appeals and case-by-case determination were beyond the scope of this investigation and therefore not examined. Future research should also examine insurance coverage for gender-affirming dermatologic procedures such as botulinum toxin and filler injections in patients suffering from related gender dysphoria.

Insurance coverage for gender-affirming hair removal is happening now. Dermatologists, and other qualified providers, can play an important role in increasing access to and providing medically necessary hair removal procedures as part of gender-affirming dermatologic care.