Disparities in Facial Feminization Surgery Coverage: MassHealth Versus Private Insurance Coverage in Massachusetts

Abstract

Background: Facial feminization surgery (FFS) is a component of gender-affirming care for transgender women and includes a variety of surgical procedures with the unified goal of improving patients' quality of life and mitigating mental distress. This study examined insurance coverage, costs, and claim denials for commonly desired FFS procedures in Massachusetts.

Methods: Data from the Massachusetts Center for Health Information and Analysis claims database (2016-2021) were analyzed for transgender patients undergoing FFS procedures in Massachusetts. The study focused on comparing costs and denial rates between public and private insurance for frontal bone reduction, eyebrow lift, upper and lower blepharoplasty, canthopexy, rhinoplasty, genioplasty, and tracheal shave.

Results: A total of 656 FFS claims were analyzed, with tracheal shave as the most frequently claimed procedure (n = 176), followed by rhinoplasty (n = 165). Private insurance patients incurred 2-4 times higher out-of-pocket costs than public patients, who generally had no copayments. Additionally, private insurance exhibited significantly higher claim denial rates compared with public insurance.

Conclusions: Our findings revealed significant differences in insurance coverage, reimbursement, and claim denials for procedures across different insurance types in Massachusetts. These differences arise from varying interpretations of medical necessity, the dual cosmetic and functional nature of certain procedures, and the deeply personal experience of gender dysphoria. Our findings emphasize the need for expanded outcomes research on the efficacy and potential complications of FFS to better inform and enhance the comprehensive care provided to transgender patients.

Fig. 1.

Comparison of masculine and feminine facial features with corresponding FFS procedures. The illustration shows a masculine face with a feminine face overlay (blue). Key differences are highlighted: (1) forehead: masculine features include greater supraorbital prominence and a narrower nasofrontal angle, addressed by FFS through frontal bossing reduction and contouring. (2) Nose: masculine traits include a higher nasal bridge and wider alar base, modified by FFS via rhinoplasty. (3) Chin: masculine characteristics include longer vertical mandibular length and a wider square chin, feminized through FFS genioplasty.

Fig. 2.

Comparison of masculine and feminine eye characteristics. The illustration shows a masculine eye with a feminine eye overlay (dark blue). Red and cyan lines indicate that the feminine eye has a greater canthal tilt. Additionally, the masculine eyebrow is flatter and aligns with the superior orbital rim, whereas the feminine eyebrow is more arched and positioned above the superior orbital rim.

Fig. 3.

Method of identification of transgender individuals and filtering of data for all FFS procedures of interest. The numbers shown represent the filtered claims relevant to the study, not the total claims in the database.