National Analysis of Insurance Coverage for Gender-Affirming Surgery in the United States

Purpose: This study reviewed the U.S. insurance landscape for gender-affirming surgery (GAS) and examined how regional, legislative, and health care infrastructure factors influence coverage patterns to inform policy reform and advocacy. Methods: Policies from the top three insurers in each state, identified via the National Association of Insurance Commissioners, were analyzed in November 2024. Coverage was compared across census regions, and criteria concordance with the World Professional Association for Transgender Health (WPATH) Standards of Care, Version 8, was assessed. GAS fellowship availability, policy information accessibility (7-point Likert scale), and legislative favorability (Movement Advancement Project scores) were also evaluated. Coverage rates were compared across procedures using analysis of variance with post hoc Tukey tests. Poisson regression identified predictors of coverage, and ordinal logistic regression assessed predictors of policy information accessibility. All analyses were conducted in R 4.4.1. Results: We included 144 state insurance policies, representing 77% of the U.S. market. Overall GAS coverage was 67.7%, with significantly lower rates for fertility cryopreservation (6.6%), facial feminization (37.3%), and GAS reversal (65.7%). GAS fellowship presence positively predicted coverage ( p < 0.001). States with fair ( p = 0.041) or medium legislative favorability ( p = 0.004) had higher coverage compared with negatively rated states. Only 61.9% of policies were concordant with WPATH guidelines. Coverage information access was uniformly limited and was more limited in Southern states than in other regions ( p < 0.001). Conclusion: Insurance coverage for GAS was inconsistent and strongly influenced by political and health care infrastructure factors rather than medical necessity. The lack of guideline concordance and systematic information barriers highlights the need for targeted reforms.