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

Access to gender-affirming chest masculinization surgery (CMS) is shaped by health policy and insurance coverage. This retrospective study examines insurance denials and surgical wait times over a ten-year period among transgender and nonbinary (TGNB) adults at a Midwestern academic center in the United States. Patients presenting for CMS consultations from 2014 to 2024 were included in this retrospective cohort study. Insurance type, denials, and wait times were analyzed using chi-square and t-tests. One-way ANOVA assessed the effects of consultation year and gender-affirming hormone therapy (GAHT) duration on wait time (p < 0.05). Of 128 patients, 89 (70%) progressed to surgery. Mean time to surgery was 249 days (8.2 months) with no significant difference between nonbinary individuals and transgender men (p = 0.35). Nonbinary patients were more likely to have private insurance (p = 0.01) and less likely to utilize GAHT (p < 0.01). Insurance denials occurred in 21%, the majority from public insurers (n = 18, 67.0%). Consultation year was associated with prior authorization approval (p = 0.01) and wait time (p < 0.01), while insurance type (public vs. private) assessed by year (p = 0.13–0.93) and GAHT duration (p = 0.09) did not demonstrate a significant association with wait time. Progression to CMS and wait times were associated primarily by consultation year rather than insurance type, likely reflecting policy changes such as the implementation of nondiscrimination protections under Sect. 1557 of the Affordable Care Act. These trends provide meaningful insights to patients and providers in planning for surgery and highlight the vulnerability of state-level access to evolving federal policy.