Background Facial feminization surgery (FFS) is a crucial component of gender-affirming care (GAC) for transgender women, significantly improving quality of life and mitigating mental distress. Despite its importance, FFS coverage remains contentious due to the nuanced distinction between cosmetic procedures and medically necessary interventions. Massachusetts stands out as one of only three states offering extensive coverage for facial gender-affirming surgeries. This study aims to examine what "extensive coverage" truly means for those seeking FFS under MassHealth insurance. We investigated insurance coverage, average cost, and claim denials of three commonly desired FFS procedures in Massachusetts: rhinoplasty, frontal lobe reduction, and genioplasty.

Methods This retrospective study utilized data from the Massachusetts Center for Health Information and Analysis (CHIA) claims database from 2016 to 2021. Transgender patients were identified by ICD-10-CM codes. The data was filtered for CPT procedure codes for the three FFS of interest. Analysis was performed to compare the cost of procedures for patients with MassHealth versus private insurance, including mean amount paid and percentage of denied claims.

Results From 2016-2021, there were 454 rhinoplasties, 260 frontal bone reductions, and 226 genioplasties billed as GAC FFS in Massachusetts. After filtering to include only the highest version of paid claims, the dataset was reduced to 165 claims for rhinoplasty (18 MassHealth, 147 private), 93 for frontal bone reduction (7 MassHealth, 86 private), and 80 for genioplasty (2 MassHealth, 78 private).

Under MassHealth, the average costs for rhinoplasty, frontal bone reduction, and genioplasty were $1,596, $167, and $395, respectively. For private insurance, the mean costs were $5,443, $2,268, and $5,801 respectively. MassHealth denied no claims for rhinoplasty and genioplasty, while private insurance denied 12.3% and 8.1% respectively. For frontal bone reduction, MassHealth denied 0.4% of claims, compared to 7.1% denied by private insurance.

Conclusion Our findings highlight significant differences in FFS procedure coverage in Massachusetts, with privately insured transgender individuals facing greater financial burdens and higher denial rates. This research contributes to evidence demonstrating disparities in access to and coverage for FFS. We hope these results will inform future policy decisions to improve equitable access to these medically necessary procedures. Insurance companies across the United States may consider modeling their coverage policies after MassHealth to offer a more comprehensive approach to GAC, potentially improving health outcomes and reducing disparities for transgender individuals.