Insurance Denials for Chest Masculinization Surgery Fell Sharply Over a Decade of Policy Change

A single academic medical center in the American Midwest has quietly produced one of the most detailed longitudinal pictures yet of how federal policy reshapes access to gender-affirming surgery. In a retrospective cohort study published in BMC Plastic and Reconstructive Surgery, researchers at the University of Cincinnati Medical Center tracked 128 transgender and nonbinary adults who sought consultations for chest masculinization surgery between July 2014 and January 2024. Their central finding is striking: with each successive calendar year, the odds of a prior authorization denial dropped by 44 percent, a trend the authors link to sweeping changes in federal nondiscrimination law rather than to the type of insurance a patient carried. For a procedure that accounts for more than half of all gender-affirming surgeries performed in the United States, the decade-long trajectory offers both reassurance and a warning about how fragile that progress may be.

Chest masculinization surgery, often called gender-affirming top surgery, is considered medically necessary for many transgender and nonbinary people experiencing chest dysphoria, the distress arising from a mismatch between chest anatomy and gender identity. The operation encompasses a range of techniques tailored to individual anatomy and goals, with double-incision mastectomy with free nipple grafting the most common approach. The evidence base supporting the procedure has grown considerably. Prospective studies using validated instruments have documented significant reductions in depression and anxiety alongside improvements in body image and psychosocial functioning six months after surgery. Long-term follow-up of 139 patients two or more years postoperative reported median satisfaction scores of 5 out of 5 and decisional regret scores of 0 out of 100, with no participants seeking reversal.

Population-level data reinforce these individual outcomes. An analysis of national insurance claims found significantly lower rates of antidepressant use, suicidal ideation and attempts, and substance misuse among people with gender incongruence who had undergone gender-affirming surgery. A secondary analysis of the 2015 U.S. Transgender Survey, which included 27,715 respondents, found that those who had surgery at least two years earlier had significantly lower odds of past-month psychological distress, past-year suicidal ideation, and past-year tobacco use compared with those who desired but had not yet received surgery. Critically, the analysis controlled for prior transition-related care such as counseling and hormone therapy, isolating the surgical contribution. In the 2022 U.S. Transgender Survey of 22,285 respondents, 97 percent of those who had received surgery reported greater life satisfaction afterward.

The policy backdrop to the Cincinnati study is essential to interpreting its results. Medicare reversed its exclusion of gender-affirming surgery in 2014, and in 2016 the U.S. Department of Health and Human Services implemented Section 1557 of the Affordable Care Act, expanding the definition of sex discrimination to include gender identity and thereby prohibiting insurance discrimination against gender-affirming care. Federal regulations now prohibit categorical exclusions of such care in health plans receiving federal funding, and as of 2024, twenty-four states and the District of Columbia have enacted laws or regulations barring blanket exclusions in private insurance. The volume of surgery reflects this shift: one analysis documented a 152-fold increase in gender-affirming surgeries between 2010 and 2018, with the steepest growth, 257 percent, occurring in the Midwest during the implementation period of Section 1557.

Against that backdrop, the Cincinnati team assembled its cohort using the ICD-10 diagnosis code for gender incongruence and extracted demographic, clinical, and insurance data from the electronic medical record. The 128 patients had a mean age of 26.9 years, and 79 percent identified as transgender men while 21 percent identified as nonbinary. Public insurance was the norm, covering 64 percent of patients, including 57 percent on Medicaid. The vast majority of consultations, 90 percent, occurred in 2019 or later, underscoring how rapidly demand grew in the second half of the study window. All procedures were performed by the same group of surgeons throughout, which the authors note strengthens the internal consistency of the wait-time analysis.

The insurance findings are nuanced. Overall, 27 patients, or 21 percent, received at least one denial of prior authorization, and two-thirds of those denials came from public insurers. Yet the likelihood of denial did not differ significantly between public and private coverage, at 21 percent versus 20 percent. Seventeen of the 27 denied patients were ultimately approved after resubmission, while eight did not proceed and were lost to follow-up. Nonbinary patients were significantly less likely than transgender men to experience a denial, 7 percent versus 24 percent, a difference the authors attribute in part to the fact that all nonbinary patients were engaged in psychiatric care, which may have strengthened the medical necessity documentation supporting their authorization requests.

Wait times emerged as the study’s most policy-sensitive metric. The mean interval from initial consultation to surgery was 249 days, or roughly 8.2 months, with a median of 208 days. Publicly insured patients waited an average of 259 days compared with 218 days for the privately insured, a 41-day difference that was not statistically significant. Consultation year, by contrast, was strongly associated with wait time, with the shortest waits, 186 days, recorded in 2022. Neither insurance type assessed year by year nor the duration of gender-affirming hormone therapy independently predicted how long patients waited. That last result carries practical weight: hormone therapy duration requirements embedded in insurer policies appear to do little to expedite care, suggesting that timely progression depends more on coordinated documentation from primary care and mental health clinicians and on surgeons willing to engage in the appeals process.

Surgical outcomes added a further layer of complexity. Among the 89 patients, or 70 percent of the cohort, who underwent surgery, mean tissue resected was 875.2 grams and postoperative complications occurred in 11 percent, including infections requiring antibiotics, hematomas or seromas requiring drainage, delayed wound healing, and nipple necrosis. No patient required a return to the operating room. Nonbinary patients had significantly greater mean tissue resected than transgender men, 1410.6 grams versus 742.9 grams, and more frequently opted for a no-nipple result. They also experienced a significantly higher rate of postoperative infection, 16 percent versus 1 percent, though rates of seroma, delayed healing, and revision surgery did not differ by gender identity. The authors suggest the larger resection volumes may have contributed to the infection difference and note that similar revision rates between groups imply comparable achievement of desired aesthetic outcomes.

The study’s limitations are acknowledged candidly. Spanning nearly a decade of overlapping legal and policy changes, the retrospective design cannot isolate the effect of any single reform, and the analysis was not powered for granular year-by-year comparisons. Records may have omitted contextual details, and institutional factors are difficult to disentangle from broader trends. The single-center setting in a region without state-level nondiscrimination protections limits generalizability, particularly given that an estimated 44 percent of the LGBTQ population lives in states lacking such safeguards. Nationally, disparities persist: 28 percent of 2022 U.S. Transgender Survey respondents reported avoiding medical care due to cost, and 35 percent of those assigned female at birth who sought chest surgery reported a denial in the past year, with Medicaid recipients disproportionately affected.

Even so, the core message stands out with unusual clarity for health services research. Access to chest masculinization surgery at this Midwestern center improved primarily along a temporal gradient that tracks federal policy change, not along the insurance fault line that so often divides American health care. The authors conclude that federal policy shifts were associated with meaningful improvements in access across insurance types, even in a region lacking state-level protections, while cautioning that access remains tightly linked to policy and increasingly vulnerable to reversal amid ongoing federal reconsideration of gender identity protections under Section 1557. As the legal landscape evolves, they argue, research in the regions most exposed to policy change will be critical to understanding how these dynamics shape access to medically necessary care for transgender and nonbinary adults.

Subject of Research: Trends in insurance coverage and surgical wait times for gender-affirming chest masculinization surgery among transgender and nonbinary adults in the United States

Article Title: A decade under review—trends in insurance coverage and wait times for chest masculinization surgery in the United States

Article References: A decade under review—trends in insurance coverage and wait times for chest masculinization surgery in the United States. (n.d.). https://doi.org/10.1186/s44452-026-00020-0

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00020-0

Keywords: chest masculinization surgery, gender-affirming care, insurance denials, prior authorization, Affordable Care Act, Section 1557, transgender health, nonbinary patients, wait times, health policy, Medicaid, plastic surgery