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Introduction: In May 2014, the US Department of Health and Human Services prohibited insurance discrimination of transgender individuals. Despite this, insurance plans often lack explicit guidelines on gender transition-related care and coverage of surgical procedures is extremely varied. We evaluated the evolution of insurance coverage of gender-affirming care following the 2014 legislative change., Methods: Insurance providers were selected based on company market share. We conducted a Web-based search and telephone interviews to identify the corresponding policies related to gender-affirming health care. We compared policy changes made before and after the 2014 US Department of Health and Human Services decision., Results: Of the 92 insurers surveyed, 7% did not have a policy, and 315 policy revisions were documented. After the legislation, a significantly higher proportion of policy revisions were related to coverage of services (36% vs 11%, P < 0.0001), removal of existing criteria significantly decreased (23% vs 49%, P = 0.0044), and addition of criteria unrelated to international standards sharply increased (32% vs 2%, P = 0.0002). This resulted in reduced coverage of facial feminization, hair transplantation, laryngochondroplasty, and voice modification surgery. However, nipple reconstruction experienced increased coverage. The percentage of revisions to add preauthorization criteria to meet international standards (49% vs 45%, P = 0.6714) or to change terminology (37% vs 27%, P = 0.1055) were similar before and after the legislation., Conclusions: After the transformative legislation in 2014, an increasing number of insurance companies established gender transition-related policies. As more patients seek gender-affirming care, insurers deviate from international guidelines and create additional benchmarks that may act as barriers to care., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite the medical necessity, legislative mandates, and economic benefits of gender-affirming surgery, access to treatment remains limited. The World Professional Association for Transgender Health (WPATH) has proposed guidelines for transition-related surgery in conjunction with criteria to delineate medical necessity. The authors assessed insurance coverage of "top" gender-affirming surgery and evaluated the differences between insurance policy criteria and WPATH recommendations., Methods: The authors conducted a cross-sectional analysis of insurance policies for coverage of top gender-affirming surgery. Insurance companies were selected based on their state enrollment data and market share. A Web-based search and individual telephone interviews were conducted to identify the policy. Medical necessity criteria were abstracted from publicly available policies., Results: Of the 57 insurers evaluated, bilateral mastectomy (transmasculine) was covered by significantly more insurers than breast augmentation (transfeminine) (96 percent versus 68 percent; p < 0.0001). Only 4 percent of companies used WPATH-consistent criteria. No criterion was universally required by insurers. Additional prerequisites for coverage that extended beyond WPATH guidelines for top surgery were continuous living in congruent gender role, two referring mental health professionals, and hormone therapy before surgery. Hormone therapy was required in a significantly higher proportion of transfeminine policies compared with transmasculine policies (90 percent versus 21 percent; p < 0.0001)., Conclusions: In addition to the marked intercompany variation in criteria for insurance coverage that often deviated from WPATH recommendations, there are health care insurers who categorically deny access to top gender-affirming surgery. A greater evidence base is needed to provide further support for the medical necessity criteria in current use.