Letters of Support for Bottom Surgery

Insurance companies require the appropriate letters of support as outlined by the World Association for Transgender Health (WPATH) before surgery will be approved. While WPATH has issued its updated Standards of Care Version 8 (SOC 8), most insurance companies still follow the SOC 7 guidelines.  We recommend that you speak with your insurance provider on the specifics of what they will require in your letters. This is because while almost every insurance provider follows WPATH guidelines, they may include additional requirements and specifics that are unique to its plan. 

• For the majority of our U.S. patients, insurance usually requires 3 letters from the following per SOC 7 guidelines:

1. Mental health professional holding an advanced degree. This is often a doctorate level degree (e.g. Ph.D., Psy.D., M.D., D.O., etc)  

2. Mental health professional performing an evaluative role 

3. Hormone provider (primary care provider, specialist, etc.) 

• For some of our U.S. patients, insurance usually requires 2 letters of the following per SOC 8 guidelines:

1. Mental health professional

2. Hormone provider (primary care provider, specialist, etc.) 

   Note: If patients suspect that their insurance only requires 1-2 letters, they must provide us written documentation (e.g., excerpt from their policy) that states so. This is to avoid any confusion that could cause a surgery delay or cancellation.

• For our OHIP patients, we do not have additional requirements beyond what the Ministry of Health requires to obtain approval for the consultation and procedure

• For our international patients or those who will not be utilizing insurance coverage, we abide by WPATH SOC 8 guidelines.

Mental Health Letter Requirements  

• Identifying information: Patient’s legal name, preferred name (if different), and date of birth 

• The mental health provider must state their qualifications in the diagnosis and treatment of gender dysphoria. 

• Diagnosis: A statement that the patient has been diagnosed with persistent, well-documented gender dysphoria, including: 

• The desire to live and be accepted as a member of the gender identity, including the desire to make their body as congruent as possible with the gender identity through surgery 

• The transgender identity has been present persistently for at least two years; and 

• Gender dysphoria is not a symptom of another mental health disorder; and 

• The gender dysphoria causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

• 12 continuous months of living in a gender role that is congruent with their gender identity.  

• 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones). 

• The patient has the capacity to make a fully informed decision and to consent for treatment. 

• The patient can comply with long term follow-up requirements and post-operative expectations have been addressed. 

• If significant medical or mental health concerns are present, they must be well controlled. 

Hormone Provider Letter Requirements 

• Identifying information: Patient’s legal name, preferred name (if different), and date of birth 

• The start date of the patient-provider relationship and frequency of meeting.  

• 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones). 

• Explicit start date should be included along with specific regimen. 

Frequently Asked Questions

• SOC 7 says 2 letters, but you’re saying I need 3 letters. Why?

  • All insurances require a letter that would come from your HRT provider as they would need to see continuous HRT. The only way an insurance can confirm ongoing HRT is through a letter from your provider. The alternative would be a documented contradiction to HRT described by your qualified mental health professional. Too often, we have seen insurance deny coverage as a consequence of not providing all letters. To avoid this extremely unfortunate outcome for our patients, which can lead to surgery delays or cancellations, we always submit our authorization packets with all letters.

• SOC 8 says 1 letter, but you’re saying I need 2 letters. Why?

  • See answer above

• Can I schedule surgery before all of my letters are complete and submitted?

  • No. We must have all of your letters in hand (via email or fax) in order to reserve your spot on the surgery calendar.

• My policy states that letters must be dated within a year of my surgery. What if my surgery is reserved beyond a year?

  • Closer to your surgery date, you will request to your letter providers to update your letters. Our team will send you a courtesy reminder 6 months from your reserved surgery date. Please make sure to remain in contact with your letter providers so that this process is easy.

• I have had multiple hormone providers over my transition period. Does this mean I need all of them to write me letters?

  • No. You may ask your most recent hormone provider to write your letter and outline your hormone protocol.

References

• WPATH SOC7 Guidelines for Surgery (page 26+)

• WPATH SOC 8 Guidelines for Surgery (page 256)