I was denied top surgery from United Healthcare (UHC) on grounds that I identify as nonbinary, and not a "trans man". The fact that a medical professional denied my access to life-saving healthcare on the basis that I identify outside the gender binary was beyond invalidating and crushing. I waited months for UHC and my surgeon's office (Dr. Champaneria at Scripps) to have what is called a "peer-to-peer" appeal: when the UHC's appointed medical professional and Dr. Champaneria have a phone call. Even after multiple phone calls and promptings from my end, this never happened, so I took matters into my own hands.
I researched the scientific and legal evidence supporting nonbinary folx access to top surgery and asked my Plume healthcare provider to write a support letter (in addition to the letter I already had from a mental health provider). I encourage you to contact your local LGBTQIA+ center, and ask for support from one of their advocates to write you a letter as well.
Below is the final product of the appeal letter that made UHC go, "oh shit please don't sue us on the grounds of discrimination, and yes you can have top surgery!" Note that in the first part of the letter, I reference UHC directly. Please feel free to use this resource as it pertains to your situation, and contact me if you need additional support.
[Month] [Day], [Year]
Dear Appeal Analyst,
I am writing to appeal United Healthcare’s decision to deny Top Surgery for treatment of Gender Dysphoria.
It is my understanding that United Healthcare (UHC) is denying coverage on the basis that the “health plan covers the procedure for members transitioning from FTM or MTF” and that “[I am] not transitioning” (See Record for Denial Letter). UHC fails to recognize that the coverage has been deemed medically necessary to treat my diagnosed Gender Dysphoria and that Top Surgery is a covered plan benefit.
According to UHC’s Gender Dysphoria Treatment, updated November 1, 2020 (See Attached for UHC’s Gender Dysphoria Treatment), under the Coverage Rationale section, I meet the requirements for Gender Dysphoria according to qualified behavioral therapist, [therapist]. Contrary to the denial, which claims that I am “not transitioning,” [therapist] has explicitly stated that “[top surgery] is a good, if not necessary, decision for [me]. It only seems natural for [me] to pursue this step in [my] transition.” Further, [therapist] has deemed me of sound mind in pursuing the surgery (See Attached letter from [therapist], APCC).
Contrary to the denial, top surgery is medically necessary and covered for all transgender individuals experiencing gender dysphoria, not just those that identify within the gender binary. UHC’s Gender Dysphoria Treatment, updated November 1, 2020, has no requirement that the patient be transitioning according to FTM/MTF criteria. Regardless, I am transitioning from female assigned at birth to the nonbinary gender identity, which is an identity under the umbrella of transgender identities according to GLAAD. According to UHC’s Gender Dysphoria Treatment plan under the Clinical Evidence section, a “systematic review assessing the health of nonbinary and genderqueer individuals (NBGQ)” was conducted and “highlighted higher health needs in NBGQ individuals compared with cisgender counterparts.”
Although not required for approval of medically necessary top surgery, I have been taking testosterone, a “cross-sex hormone therapy” as termed by the World Professional Association for Transgender Health (WPATH). My gender affirmation specialist, [PCP], can attest to my ongoing treatment plan for my gender dysphoria (See Attached letter from [PCP], M.D.). My entire treatment team, including [PCP], [Top Surgeon] and [Therapist], has recommended that Top Surgery is medically necessary.
Contrary to your letter, Top Surgery is a covered service protected under Barclays California Code of Regulations. The Code of Regulations States that “A transgender person is a person (1) who has, or has been diagnosed with, gender identity disorder or gender dysphoria; (2) who has received health care services, including counseling, related to gender transition...” (10 CCR 2561.1). The Code of Regulations further outlines Discrimination on the Basis of Actual or Perceived Gender Identity in relation to Insurance Code section 106 (10 CCR 2561.2). This section supports that the denial of my claim for top surgery is discrimination based on the perception that I am not undergoing transition and that I do not belong to the transgender community.
Gender dysphoria is a serious mental health condition. Without treatment, my symptoms of gender dysphoria can increase in severity, leaving me susceptible to comorbid mental health ailments. Untreated gender dysphoria influences social and emotional impairment that can result in poor quality of life (Mahfouda et al. 2019).
Thank you for your immediate attention to this matter.
Sincerely,
[Name]
[pronouns]