Resources-International Insurance

Resources: International Insurance

GAC: Are Exclusions Ethical?

In practice, most managed-care insurers do not write “gender-affirming care is excluded” outright. Instead, they cover a defined subset of gender-affirming services only when their “medical necessity” criteria are met, and they treat everything else as “not medically necessary/not covered” (often labeling it cosmetic, experimental, or contract-excluded).

Are GAC Exclusions Ethical?

Question:

“Is it ethically acceptable for an insurance provider to require a patient to commit to future gender-affirming surgery as a condition of receiving a non-surgical gender-affirming treatment (e.g., hormone therapy, puberty suppression, voice therapy, hair removal, supportive counseling, etc.)?”

Answer:

No.

Conditioning a non-surgical intervention on commitment to surgery undermines patient autonomy by introducing undue influence. Ethical informed consent requires that choices be voluntary and aligned with the patient’s values/goals. When access to needed care depends on agreeing to another, more invasive intervention, the patient’s decision-making becomes structurally constrained rather than genuinely self-directed.

Beneficence

Non-surgical gender-affirming treatments can be clinically appropriate and beneficial independent of surgery. Requiring a surgical commitment risks denying an indicated treatment that may alleviate distress, improve functioning, and support health.

It also may reduce trust and engagement with care.

Nonmaleficence (avoiding harm)

This requirement can cause harm by:

escalating distress/dysphoria and anxiety,
pressuring premature decisions about irreversible interventions,
encouraging strategic or inaccurate disclosures (“I’ll say I want surgery to get hormones”), and
increasing risk of disengagement from care.

Summary:

The practice introduces preventable harms without clear medical necessity. In effect, this creates a barrier that disproportionately affects:

patients who do not desire surgery.
patients unsure about surgery.
patients facing financial/medical/access barriers, and
patients seeking partial or individualized gender affirmation.

Ethically, access to medically indicated care should not be restricted based on a preferred “trajectory” of gender transition.

The practice raises justice concerns and functions as gatekeeping.

Ethics Informed Recommendations

Decouple non-surgical care exclusions from any attachment to plans for imminent or future surgical procedure(s).
Provide the requested non-surgical intervention using a minimally complex pre-approval / informed consent / shared decision-making model.
Ensure documentation reflects:

patient goals and preferences,
informed consent discussion,
individualized risk/benefit analysis, and
rationale for any limitations based solely on clinically relevant factors.

If this is a systemic gender-affirming care coverage exclusion, review policy for equity, non-discrimination, and least restrictive access.

Pre-Existing Condition Traps

If you have already received a diagnosis of Gender Dysphoria or started HRT before buying an individual policy, the insurer may classify the entire transition as a pre-existing condition and exclude it entirely.

Definitions/Acronyms

Clinical/Coverage Policy Bulletin (CPB)

“CPB” stands for Clinical Policy Bulletin (or Coverage Policy Bulletin), which is an insurer-issued periodical update on changes to, or clarification of what is considered medically necessary care, and what the criteria is for accessing that care.

Table of Benefits (TOB)

An insurer “Table of Benefits” defines the care that is covered under your plan, where you can access that care, and what limits/prior-authorization requirements exist related to that care.

Insurance Brokers

What To Look For

If you are evaluating an international plan, check the “General Exclusions” section for these specific terms:

“Gender reassignment or sex change surgery and any related treatment.”
“Services or supplies for or in connection with a change of gender.”
“Cosmetic surgery, except for reconstructive surgery following an accident or cancer.” (This is often used to deny GAC).

Speaking To An Insurance Broker

When speaking with an insurance broker about international plans, be direct and assertive. General questions about “LGBTQ+ friendly” plans often lead to vague answers. You need to ask for specific legal and clinical definitions in the policy.

Here is a checklist of high-value questions and strategies to ensure you get clear answers.

1. The “Killer Question” for Blanket Exclusions

Many international brokers will say a plan “covers surgery” without mentioning it excludes gender-related ones.

Ask this first:
“Does this plan have any categorical exclusions for treatment, surgery, or medication related to ‘gender reassignment,’ ‘gender identity,’ or ‘sex transformation’?”

2. Verification of “Medical Necessity”

International plans often have their own definitions of “medical necessity” that may not match WPATH.

Ask:
“What clinical standard does the insurer use to determine if gender-affirming care is medically necessary? Does the plan strictly follow the WPATH Standards of Care (SOC 8)?”

3. Drilling Down into Specific Procedures

“Gender reassignment surgery” in an insurance contract sometimes only means genital surgery.

If you need other care, ask:

For FFS/FMS: “Does the plan classify facial gender confirmation surgery (e.g., brow contouring, jaw reduction) as reconstructive or cosmetic for patients with a gender dysphoria diagnosis?”
For Hair Removal: “Is laser hair removal or electrolysis covered if it is required for surgical site preparation or to treat gender dysphoria?”
For Voice: “Does the benefit include speech therapy or surgical voice modification (e.g., tracheal shave or glottoplasty)?”

4. Group vs. Individual Differences

If you are getting this plan through an employer, the rules are different.

Ask your broker:
“Is the gender-affirming care benefit part of the standard policy wording, or is it an optional rider? If it’s a rider, are there separate lifetime or annual financial caps for these services?”

5. The “Paper Trail” Strategy

Brokers often make verbal promises that don’t hold up during a claim. Use this strategy to get proof:

Ask for the “Full Policy Wording”: Do not rely on the “Summary of Benefits.” Ask for the 50+ page PDF that contains the “General Exclusions” section.
Request the “Clinical Policy Bulletin” (CPB): Most major carriers (like Aetna or Cigna) have a specific document titled “Gender Affirming Surgery” or “Treatment of Gender Dysphoria.” This document lists every single procedure they cover and the exact requirements (letters, years on HRT) to get them.

Red Flags to Watch For

If your broker says any of the following, the plan likely does not provide the coverage you need:

“It’s covered if it’s not cosmetic.” (This is a trap; without a specific TGI policy, they will label everything as cosmetic).
“We don’t have a specific policy, but they usually approve it.” (This means you will likely have to fight a denial later).
“Hormones are covered under the pharmacy benefit.” (This doesn’t mean the surgeries are covered).

Insurance Broker: Inquiry Template

When contacting an insurance broker or HR about international health insurance (IPMI), you need to get them to look beyond the “Summary of Benefits” and check the Clinical Policy Bulletins or the full Certificate of Insurance.

Below is a professional email template designed to pin down whether a plan has hidden exclusions for gender-affirming care (GAC).

Don’t forget to check out the “Pro Tips” at the bottom of the next column.

Subject: Inquiry regarding specialized coverage and clinical policy for Gender-Affirming Care

Dear [Broker/HR Representative Name],

I am evaluating [Plan Name] for my international health coverage. To ensure this policy meets my medical needs, I require clarification on the plan’s specific clinical policies regarding the treatment of Gender Dysphoria and Gender-Affirming Care (GAC).

Standard “Summary of Benefits” often lack the detail necessary to distinguish between reconstructive and cosmetic procedures for transgender members. Could you please provide the following information:

Categorical Exclusions: Does this policy contain any categorical exclusions for “Gender Reassignment,” “Sex Transformation,” or “services related to gender identity”? Please check the “General Exclusions” section of the full Policy Wording.
Clinical Standard: Does the insurer utilize the WPATH Standards of Care (SOC 8) to determine medical necessity for gender-affirming procedures?
Scope of Reconstructive Surgery: Under California state law (if applicable) or the insurer’s global policy, are the following procedures classified as “Reconstructive” (and therefore covered) when deemed medically necessary to treat Gender Dysphoria?

Genital Gender-Affirming Surgery (Vaginoplasty/Phalloplasty)
Chest Reconstructive Surgery (Mastectomy/Breast Augmentation)
Facial Gender Confirmation Surgery (FFS/FMS)
Voice Modification Surgery and Speech Therapy

Hormone Replacement Therapy (HRT):

Is HRT covered under the outpatient pharmacy benefit, and are related laboratory services (such as blood monitoring) covered as standard medical care?

Benefit Riders:

If these services are not included in the core plan, is there a “Gender Affirmation Rider” available for purchase? If so, what is the lifetime financial cap for that rider?

Please provide the Clinical Policy Bulletin or the “Medical Necessity Guidelines” document specific to Transgender Health for this carrier so that I may review the exact requirements for prior authorization.

Thank you for your assistance in ensuring this plan provides comprehensive, ethical, and non-discriminatory care.

Sincerely,

[Your Name]

[Your Contact Information]

Pro-Tips for the 2026 Landscape:

Mention WPATH SOC 8: In 2026, many older plans still refer to SOC 7. Insisting on SOC 8 is important because it is more inclusive and removes many of the older “gatekeeping” requirements (like the mandatory 1-year therapy “real life test” for some surgeries).
The “State-Situs” Check: If the broker says the plan follows federal U.S. law, ask: “Which state is this policy ‘sitused’ in?” If it’s sitused in California, Washington, or New York, you have much stronger legal protections than if it’s sitused in a state with active bans.
Don’t Forget Pharmacy: Some international plans cover surgery but exclude “lifestyle drugs.” You must ensure they don’t classify testosterone or estrogen as a lifestyle drug.

Insurance Companies

Aetna International (Pioneer/Summit)

Generally follows the clinical policies of Aetna U.S., which recognizes gender-affirming surgery as medically necessary. They are a common choice for multinational companies seeking to offer consistent benefits to transgender employees worldwide. Aetna generally has the most robust coverage because they align their international clinical policies with their U.S. standards (WPATH-based).

Medically Necessary (Covered):

Genital Surgery: Vaginoplasty, phalloplasty, and orchiectomy (requires 12 months of HRT).
Chest Surgery: Mastectomy and breast augmentation (requires 6 months of HRT for augmentation).
Facial/Body: Aetna’s CPB 0615 specifically lists facial feminization surgery (FFS), voice surgery, and liposuction as medically necessary if WPATH criteria are met.

2026 Shift: Aetna has issued a “Sex-Trait Modification Services” update for 2026. While they have removed coverage for federal employees (FEHB) due to new U.S. executive orders, their private international plans (Pioneer) still maintain coverage based on medical necessity
Clinical Requirements: Aetna requires:
- One letter from a mental health professional.
- Documented “marked and sustained” gender dysphoria.
- 12 months of hormone therapy for most genital surgeries (though only 6 months for breast surgery).
Age Limits: As of 2026, many Aetna international plans now restrict surgical coverage to those 18 and older, even in regions where it was previously allowed for younger ages.

Aetna Designated Surgeons PDF

Allianz Care

Some Allianz Care health plans explicitly include coverage for gender-affirming surgery (often archaically described as “gender reassignment surgery”) if you meet plan criteria for gender dysphoria services. However, other Allianz Care plans may exclude “care and/or treatment or services for gender dysphoria” unless your plan includes a specific benefit/rider. Coverage is plan-dependent and criteria-driven, and is not automatic across all plans or countries.

Often lists “Gender reassignment” under their general exclusions unless it is specifically added as an optional rider or included in a high-tier corporate group plan.

Allianz Care’s Summit Employee Benefit Guide (2025) contains a dedicated “Gender-affirming care” section (ppg 45-47) describing coverage for medically necessary treatments and services for gender dysphoria, subject to local laws and regulations.

Pre-authorisation is very likely for surgeries / high-cost care

Allianz Care explains that your Table of Benefits indicates whether pre-authorisation is required, and that pre-authorisation is typically tied to in-patient and other high-cost treatments.

Practically:

If you pursue surgery (or anything treated as high-cost), assume you’ll need pre-authorisation.
If you skip it, you can end up declined for Missing Pre-authorization (MPA).

Bupa Global

Many of their standard international private medical insurance (IPMI) contracts historically exclude gender-affirming surgery, categorizing it as “cosmetic” or “lifestyle” treatment, though they often cover mental health support for gender dysphoria.

Bupa Global (Elite/Premium)

Bupa historically had the strictest exclusions, but they have modernized their 2026 corporate offerings.

Individual Plans: Most individual Bupa Global plans (like Major Medical or Select) still list gender reassignment as a categorical exclusion.
Corporate Plans: For large companies, Bupa offers a “Gender Affirmation” rider. This is generally a lifetime financial cap (e.g., £50,000 or $100,000), which is different from most U.S. plans that have no cap.
Waiting Periods: Bupa generally enforces a 12-to-24-month waiting period. You must be on the plan for two years before you can file a claim for surgery.
Common Exclusions: Bupa often excludes “cosmetic” feminization, such as facial bone remodeling or hair transplants, even if the plan covers genital surgery.

Finding A Surgeon

Bupa typically does not list “surgeons”; they list “hospitals.” If your Bupa plan has the GAC rider, you must choose a hospital in their Elite or Premium network.

UK Focus: They rely heavily on the NHS Gender Identity Clinics (GIC) system for referrals, but may pay for private surgeons like those at the Gender Clinic at 10 Harley Street.
International: Bupa Global members in Europe often use their “MemberWorld” app to search for “Gender Specialists.” Note that Bupa generally requires you to see an endocrinologist first to establish the clinical pathway before they will release a list of surgeons.

Cigna Global

One of the more progressive international options. They frequently offer coverage for gender reassignment surgery and hormone therapy as part of their “Platinum” tier plans or custom corporate packages. However, they still require strict adherence to medical necessity criteria (similar to WPATH standards).

While Cigna is one of the most transparent international carriers regarding gender-affirming care (using a “reconstructive” vs. “cosmetic” framework), their coverage is split between their “Global” (expat) side and their “State-regulated” side.

The Exclusion: In many standard individual Cigna Global policies, you will still find Exclusion #43: “Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex unless such services are deemed Medically Necessary or otherwise meet applicable coverage requirements.”
The “Platinum” Exception: On high-tier Platinum plans or corporate group plans, the above exclusion is often waived.

Covered (if not excluded):

Top Surgery: Mastectomy and breast augmentation.
Bottom Surgery: Vagina/phalloplasty, including electrolysis for donor site preparation.
Voice/Face: Cigna’s 2026 policy specifically includes Thyroid Chondroplasty (Adam’s apple reduction) and Voice-modification surgery as medically necessary in certain cases.
System Update: Cigna has removed gender requirements in their claims systems, meaning a “male” identified member can file a claim for a mammogram without an automatic system rejection.

Finding A Surgeon

Cigna has upgraded its directory for 2026. Instead of a separate PDF, they now allow doctors to “self-identify” as GAC specialists.

How to Search: Log into your Cigna Global portal and filter by “LGBTQ+ Attributes.” Look specifically for providers tagged with “Gender Dysphoria” or “Transgender Health.”
International Strength: Cigna is particularly strong in Europe and Southeast Asia.

Thailand: Like Aetna, they have direct-billing agreements with top centers like Asia Cosmetic Hospital (Dr. Tanongsak) and Yanhee.
Europe: They work extensively with the Parkside Hospital in London and various clinics in Spain (where many FFS specialists are located).

Note: Reversal of gender affirmation procedures is almost universally excluded.

International: Insurer Summaries

Important Framing:

For international insurers, GAC coverage is almost always a two-step test:

Clinical Policy Benefits (CPB)/medical necessity criteria (what’s eligible), and
Your Table of Benefits (ToB)/Certificate (what your plan actually pays for, where, and with what limits).

Important “In-Network” Warning for 2026

Even if a surgeon is “in-network,” you must obtain Pre-Certification (also called Prior Authorization) before the surgery.

If you travel to Thailand or San Francisco without an Authorization Letter from the insurer, the surgeon/surgical center may refuse to perform the procedures unless you pay 100% of the bill.

Aetna International
Allianz Care
Bupa Global
Bupa Global (Elite/Premium)
Cigna Global

How GAC is "defined" in plan documents:

Often relies on Aetna medical policy criteria for what is medically necessary, plus your plan’s ToB for what is covered. Aetna’s CPB outlines eligibility criteria and lists covered vs. non-covered procedures.

Typical covered components (when included):

Surgical care may be considered medically necessary if criteria are met (e.g., documentation, clinical criteria).

Typical exclusions/contraints to watch:

Coverage is plan-dependent (employer and region matter). “Cosmetic” categorization risk for certain procedures depending on plan/policy interpretation.

Pre-authorization/utilization controls:

Precert/prior approval is a common requirement for surgery (Aetna uses precert workflows and forms for gender-affirming surgery requests).

What you must verify in YOUR Table of Benefits:

Does your ToB explicitly include: gender dysphoria treatment, surgery benefits, network rules, out-of-area approvals, and any benefit caps?

How GAC is "defined" in plan documents:

Some plans have a specific “Gender-affirming care” section and state that medically necessary services for gender dysphoria may be covered subject to local law and ToB inclusion.

Typical covered components (when included):

Can include behavioral health counseling, and gender-affirming procedures/surgery if you meet criteria and the benefit is included in your policy.

Typical exclusions/contraints to watch:

Coverage can be limited by: local legal restrictions, plan design, and older plan wordings. Allianz explicitly ties availability to whether the benefit appears in the Table of Benefits.

Pre-authorization/utilization controls:

High likelihood of pre-authorization for surgery and higher-cost care (varies by plan). The “included in your policy/ToB” clause is central.

What you must verify in YOUR Table of Benefits:

Does your ToB list gender dysphoria/gender-affirming care as a covered benefit? Are there geographic/provider restrictions and pre-auth requirements?

How GAC is "defined" in plan documents:

Many Bupa Global international plans treat GAC as a distinct benefit line item and administer it through pre-authorization workflows.

Typical covered components (when included):

When the benefit exists, it can include hormonal and surgical treatment for gender dysphoria (plan-dependent). Pre-auth is strongly encouraged/required for covered care.

Typical exclusions/contraints to watch:

Common constraints: “reasonable and customary” cost limits outside network; possible shortfalls even if pre-authorised if provider is out-of-network.

Pre-authorization/utilization controls:

Bupa emphasizes pre-authorisation processes (especially for major treatment; U.S. treatment often requires it).

What you must verify in YOUR Table of Benefits:

Does your ToB include a dedicated gender dysphoria benefit, and does it pay from a special bucket vs. general surgery/outpatient? What are network and customary-charge rules?

How GAC is "defined" in plan documents:

Elite/Premium-type plan guides may include an explicit benefit: “Treatment for or related to gender dysphoria” with special payment structure.

Typical covered components (when included):

Often described as paid in full for hormonal and surgical treatment for or related to gender dysphoria instead of any other benefit; mental health paid under mental health benefit limits.

Typical exclusions/contraints to watch:

Structural constraint: the gender dysphoria benefit can replace other benefit categories for those services (“instead of any other benefit”), which affects how claims must be coded/routed.

Pre-authorization/utilization controls:

Pre-authorisation is typically required/expected for major treatment pathways in Bupa Global.

What you must verify in YOUR Table of Benefits:

Confirm the exact wording for: paid in full, the “instead of any other benefit” rule, mental health limits, and any surgery/provider eligibility requirements.

How GAC is "defined" in plan documents:

Cigna Global plans are governed by Policy Rules + Certificate/Customer Guide, and medical necessity is often anchored to Cigna coverage policies for gender dysphoria treatment.

Typical covered components (when included):

When included, coverage may extend to medically necessary gender dysphoria treatment as defined by Cigna’s clinical coverage policy criteria.

Typical exclusions/contraints to watch:

Coverage is highly plan-specific; many Cigna entities only provide utilization review (not coverage decisions), so your plan document controls.

Pre-authorization/utilization controls:

Expect prior authorization/utilization review for surgical and higher-cost services; criteria and paperwork requirements matter.

What you must verify in YOUR Table of Benefits:

Check your Certificate/ToB for: explicit inclusion/exclusion, area of cover, provider/network rules, caps, and any gender dysphoria-specific benefit category references.

Pediatric Gender-Affirming Care

Below is a pediatric-focused summary of gender-affirming care (GAC) benefit categories insurers may cover when the benefit is included in the member’s Table of Benefits (ToB) and when pre-authorization/medical-necessity criteria are met.

Aetna International
Allianz Care
Bupa Global
Bupa Global (Elite/Premium)
Cigna Global

Minors can be enrolled as dependents?:

Yes (plan dependent)

Behavioral Health (assessment/therapy):

Commonly covered (if included + criteria met)

Puberty Blockers/Endocrine Meds:

Conditional/plan-dependent

Gender-Affirming Hormones (GAHT):

Conditional/plan-dependent

Gender-Affirming Surgeries (for minors):

Conditional (policy contemplates adolescents)

Notes/Constraints to Expect:

Aetna’s clinical policy explicitly references adolescents <18 and includes stricter duration requirements (e.g., 12 months hormone therapy for adolescents for certain procedures). Some Aetna employer guides state non-surgical treatment for minors (hormones + mental health) is covered under the plan.

Minors can be enrolled as dependents?:

Yes (dependent commonly covered)

Behavioral Health (assessment/therapy):

Conditional/plan-dependent

Puberty Blockers/Endocrine Meds:

Conditional/plan-dependent

Gender-Affirming Hormones (GAHT):

Conditional/plan-dependent

Gender-Affirming Surgeries (for minors):

Conditional (policy contemplates adolescents)

Notes/Constraints to Expect:

Allianz states gender-affirming procedures and surgery may be covered if criteria are met and the benefit is included in your policy. Practical limitation: coverage is frequently constrained by local law/regulation and pre-authorization rules.

Minors can be enrolled as dependents?:

Yes (commonly structured with dependents)

Behavioral Health (assessment/therapy):

Conditional/plan-dependent

Puberty Blockers/Endocrine Meds:

Conditional/plan-dependent

Gender-Affirming Hormones (GAHT):

Conditional/plan-dependent

Gender-Affirming Surgeries (for minors):

Conditional/plan-dependent

Notes/Constraints to Expect:

Some Bupa Global materials show a dedicated benefit line: “Treatment for or related to gender dysphoria” (often “subject to eligibility”). However: public-facing global materials rarely specify pediatric coverage explicitly—so ToB wording is decisive.

Minors can be enrolled as dependents?:

Yes (plan structure allows families)

Behavioral Health (assessment/therapy):

Conditional/plan-dependent

Puberty Blockers/Endocrine Meds:

Conditional/plan-dependent

Gender-Affirming Hormones (GAHT):

Conditional/plan-dependent

Gender-Affirming Surgeries (for minors):

Conditional/plan-dependent

Notes/Constraints to Expect:

Elite/Premium-type guides describe a specific benefit: “Treatment for or related to gender dysphoria”, paid under a dedicated bucket, with mental health paid under mental health limits. Age restriction warning: some Bupa employer/corporate gender dysphoria benefits are explicitly 18+ for diagnosis/support tiers.

Minors can be enrolled as dependents?:

Yes (plan-dependent)

Behavioral Health (assessment/therapy):

Conditional/plan-dependent

Puberty Blockers/Endocrine Meds:

Conditional/plan-dependent

Gender-Affirming Hormones (GAHT):

Conditional/plan-dependent

Gender-Affirming Surgeries (for minors):

Conditional/plan-dependent

Notes/Constraints to Expect:

Cigna’s coverage policy for Gender Dysphoria Treatment states it applies unless otherwise specified in the benefit plan and that benefit limitations/prior authorization apply. In practice, the ToB/certificate is the controlling document for pediatric coverage scope.

Insurer CPBs & TOBs

Below is a practical “how to read them together” comparison of the Clinical Policy Bulletin/Coverage Policy (CPB) versus the Table of Benefits (ToB) for international gender-affirming care (GAC) across Aetna, Allianz Care, Bupa Global, Bupa Global (Elite/Premium), and Cigna Global managed care plans.

Important “In-Network” Warning for 2026

Even if a surgeon is “in-network,” you must obtain Pre-Certification (also called Prior Authorization) before the surgery.

If you fly to Thailand or San Francisco without an Authorization Letter from the insurer, they may refuse to pay, leaving you to pay 100% bill.

Aetna International
Allianz Care
Bupa Global
Bupa Global (Elite/Premium)
Cigna Global

CPB/Coverage Policy Typically Decides

Which gender-affirming procedures are medically necessary vs cosmetic/not covered under Aetna’s criteria (e.g., surgery types, documentation requirements).

Table of Benefits Typically Decides

Whether the plan actually includes those benefits; geographic coverage, network rules, prior auth, and caps (varies by plan/employer).

International GAC Implication

If you’re outside the U.S., you can still be denied if the ToB restricts geography/provider type—even if CPB criteria are met.

The Aetna "Navigator" Hack:

Aetna offers a "Transgender Personal Navigator" (email: MyPersonalNavigator@Aetna.com) who may be able to find you an in-network surgeon.

CPB/Coverage Policy Typically Decides

Allianz Care uses “benefit guide/employee benefit guide” wording to define what is eligible and what conditions must be met (often WPATH-like documentation and age rules in some editions).

Table of Benefits Typically Decides

Allianz is explicit that gender-affirming procedures/surgery are covered only if the benefit is included in your policy (i.e., in your ToB/plan schedule).

International GAC Implication

For international care, the decisive question is: does your ToB include the benefit, and what pre-auth requirements apply in your geography.

CPB/Coverage Policy Typically Decides

Bupa Global generally uses benefit-specific eligibility language rather than a U.S.-style CPB. A key concept is a dedicated benefit for gender dysphoria care.

Table of Benefits Typically Decides

The ToB often includes a distinct line: “Treatment for or related to gender dysphoria”, sometimes paid in full, and it can be “instead of any other benefit.” Pre-auth is required.

International GAC Implication

For international claims, your approval is driven overwhelmingly by the ToB benefit line + pre-auth + exclusions language.

CPB/Coverage Policy Typically Decides

Same structure as Bupa Global: eligibility rules are embedded in the product’s membership guide/terms (not a separate CPB).

Table of Benefits Typically Decides

Elite/Ultimate membership guides show the dedicated benefit; mental health may be paid under the mental health benefit limits; pre-auth required.

International GAC Implication

Elite-tier plans can be generous on the ToB line item, but you still must route the claim through pre-auth and the plan’s defined process.

CPB/Coverage Policy Typically Decides

Medical necessity criteria for gender dysphoria treatment/gender reassignment surgery.

Table of Benefits Typically Decides

Coverage depends on the customer’s benefit plan document (ToB/certificate). Cigna explicitly says coverage varies by plan.

International GAC Implication

“Meets policy” ≠ “covered.” International approvals often hinge on ToB scope + pre-auth + site-of-care rules.

Pre-Authorization Packet

When you’re building a pre-authorization packet for international GAC, use this structure:

Table of Benefits excerpt (prove the benefit exists, limits, and pre-auth rules)
CPB / Coverage Policy excerpt (prove medical necessity criteria are met)
Your clinician documentation mapped line-by-line to the policy criteria (letters, diagnosis, duration, readiness, etc.)
Procedure coding + site of care (so it lands in the correct ToB bucket)

Coverage 'Pitfalls' (Where TOBs Usually Override Policy)

Even when you clearly meet CPB/policy criteria, international GAC gets denied most often due to ToB mechanics such as:

Geographic area of cover (Worldwide vs excluding U.S., etc.).
Pre-authorisation requirement (common for surgery and for Bupa’s gender dysphoria benefit specifically).
Provider eligibility rules (recognized facility/provider requirements).
Benefit categorization (whether GAC must be billed under a special benefit line vs “general surgery”).
Exclusions + special conditions (especially with older/legacy wording (“sex reassignment surgery” or “gender reassignment surgery).

Gender-Affirming Care: Appealing Exclusions

How GAC Exclusion Works: Operational Methodology

For Managed Care Plan insurers, the denial logic commonly looks like:

“Benefit exists, but criteria not met → Not medically necessary → Not covered.”
“Procedure classified as cosmetic (or convenience) → Not medically necessary → Not covered.”
“Contract limitation (especially self-funded employer plan) → excluded regardless of medical necessity.”

The highest-volume “medical necessity” denial targets tend to be things like facial procedures, hair removal, body contouring, voice procedures, and other services the plan frames as cosmetic unless strict criteria are met (and they are documented exactly as required).

The “Cosmetic” Loophole:

Even if a plan does not have a “transgender exclusion,” many international plans have very broad cosmetic surgery exclusions.

The Conflict: Procedures like facial feminization (FFS) or chest contouring are often denied by international carriers on the grounds that they “beautify” rather than “restore function.”
Inland (U.S.-based) vs. International: While a California-regulated plan must view FFS as “reconstructive,” an international plan based in Dubai or the UK is not bound by California’s definition and can legally deny the claim as cosmetic.

Regional Variations:

The “Area of Cover” on your international plan matters.

Middle East & SE Asia: Policies issued in countries where gender-affirming care is restricted or illegal often contain mandatory exclusions to comply with local laws.
European Heritage: Plans headquartered in the UK or France are more likely to cover hormone therapy and mental health, but may have long waiting periods or high deductibles for surgeries.

Managed Care Plan: Generalized Complaint, Grievance, and Appeal Templates

These narratives can be copy/pasted to file a complaint, grievance, or appeal to your insurance provider in the event you’ve been denied coverage of a non-surgical gender-affirming care procedure because it must be tied to plans to pursue a surgical procedure in the future.

Template A:
Direct and concise, in plain language.

Template B
More formal and detailed; “policy ready”.

A

I am filing a grievance because I was told I must commit to future gender-affirming surgery to overcome a “not medically necessary” exclusion for coverage of the non-surgical gender-affirming care treatment I requested. I do not want to be pressured into surgery to receive medically appropriate non-surgical care.

Requiring a surgical commitment as a condition of non-surgical care is coercive, not clinically necessary, and interferes with my ability to make voluntary, informed decisions about my healthcare. Non-surgical gender-affirming care can be appropriate whether or not surgery is desired, and care should be based on my current medical needs and informed consent—not on agreeing to a particular transition pathway.

I am requesting:

Access to the requested non-surgical gender-affirming care without any requirement to commit to surgery,
A written explanation of the clinical rationale for the denial/condition, and
Confirmation that future care will be provided based on individualized medical assessment and informed consent rather than on a coupled requirement to pursue surgery.

B

I am submitting this grievance regarding an inappropriate exclusion placed on my access to care. I requested non-surgical gender-affirming care (e.g., [hormone therapy/voice therapy/hair removal/other non-surgical treatment]).

I was informed that, due to a “not medically necessary” gender-affirming care exclusion, I would be unable to access coverage for this non-surgical treatment unless it was coupled with a commitment to pursuing gender-affirming surgery (now or in the future).

This requirement is problematic for several reasons:

Coercion/lack of voluntary consent: Conditioning one form of care on agreement to a different, more invasive intervention undermines voluntary decision-making and informed consent. It creates undue pressure to declare interest in surgery even if surgery is not desired or if I am not ready.
Medical inappropriateness: A commitment to surgery is not a clinically necessary prerequisite for receiving non-surgical gender-affirming treatment. The appropriateness of non-surgical care should be assessed based on its own indications, risks/benefits, and patient goals—not on a mandated “transition trajectory.”
Harm and barriers to care: This condition increases distress, delays medically indicated treatment, and may force patients into misrepresenting their goals to access care. It also disproportionately burdens individuals who do not want surgery or cannot access surgery due to medical, financial, or logistical barriers.

I am requesting the following resolutions:

Immediate access to the non-surgical gender-affirming care I requested without being required to commit to surgery.
A written explanation of the rationale for the condition placed on my care and identification of any policy relied upon.
Review and correction of any clinic/department policy or practice that conditions non-surgical gender-affirming care on a surgical commitment.
Assurance that my care will proceed using an individualized, patient-centered informed consent approach consistent with ethical standards.

Patient/Member Optional Appeal Add-On

“I am not refusing or requesting surgery. I am requesting medically appropriate non-surgical care based on my current goals and informed consent. My eligibility for non-surgical treatment should not be determined by whether I intend to pursue a separate surgical intervention.”

Provider Support Letter: Template

This provider-support letter template is designed to be persuasive across Aetna, Cigna, and Bupa Global insurers. It is written in clinical/utilization-review language, focuses on medical necessity + individualized care + decoupling non-surgical care from surgical intent, and avoids overreaching claims.

It can be pasted into a clinic letterhead format. [Bracketed] fields are placeholders.

[Clinic/Medical Group Letterhead]
[Date]

RE: Medical Necessity / Clinical Support for [Non-surgical gender-affirming service]
Patient: [Full Name]
DOB: [MM/DD/YYYY]
Member ID / CIN: [If applicable]
Plan: [Aetna / Cigna / Bupa Global / Other]
Provider: [Name, Credentials]
NPI: [#]
Address / Phone / Fax: [Contact info]

To Whom It May Concern,

I am [treating clinician / prescribing clinician / supervising clinician] for [Patient Name], whom I have evaluated and/or treated in my clinical practice. I am writing to provide clinical support for [requested non-surgical gender-affirming care service] and to clarify that access to this non-surgical treatment should not be conditioned on any commitment to future gender-affirming surgery.

1) Requested Service

I am requesting authorization/coverage for:

Service: [e.g., gender-affirming hormone therapy / puberty suppression / voice therapy / hair removal / behavioral health support / other]
Dose/Frequency/Duration (if applicable): [details]
CPT/HCPCS (if known): [code(s)]
Diagnoses/Clinical indications: [e.g., gender dysphoria / gender incongruence / related symptoms, as clinically appropriate]
Treating Provider(s): [names/roles]

2) Clinical Rationale and Medical Necessity

Based on my clinical assessment, [requested service] is medically appropriate and necessary for this patient’s current needs and goals. This non-surgical treatment is indicated to address:

clinically significant distress and/or functional impairment related to gender incongruence/dysphoria and/or associated symptoms; and
the patient’s individualized treatment goals, which may include partial or non-surgical gender affirmation.

This is a standard, evidence-informed intervention used to improve patient well-being and reduce distress. It is not investigational or elective in the sense of being optional to health; rather, it is a medically appropriate component of care when clinically indicated.

3) Independent Indication: Non-surgical care is appropriate regardless of surgical plans

It is clinically and ethically inappropriate to require a patient to “commit” to future gender-affirming surgery as a prerequisite for receiving non-surgical gender-affirming care.

Whether a patient desires surgery:

is separate from whether non-surgical care is medically appropriate;
may change over time as a patient evaluates options; and
should be determined through shared decision-making, not used as a gatekeeping condition for access to clinically indicated non-surgical treatment.

In my medical opinion, conditioning non-surgical care on an expressed intent to pursue surgery is not medically necessary, does not improve safety, and may cause harm by delaying needed treatment and undermining informed consent.

4) Patient-centered, least-restrictive care plan and monitoring

This patient is appropriate for non-surgical treatment under a patient-centered informed consent model with appropriate monitoring.

Our plan includes:

discussion of expected effects, potential risks/benefits, alternatives, and the option of no treatment;
baseline assessment and follow-up monitoring consistent with standard clinical practice;
management of any relevant comorbidities and safety considerations; and
ongoing evaluation of goals and outcomes over time.

This approach is proportionate, safe, and clinically appropriate. It does not require an intent to pursue surgery.

5) Requested Determination

I respectfully request that [Plan/IPA/UM Department] approve [requested service] based on individualized clinical need and medical necessity. Please confirm that authorization/coverage is not contingent upon the patient’s stated interest in future surgical procedures.

If coverage is denied or limited, please provide:

the specific criteria/policy relied upon,
the clinical rationale linking non-surgical eligibility to surgical intent, and
information regarding the appeal process and external review options.

Thank you for your prompt attention to this request.

Sincerely,

[Provider Name, Credentials]
[Title / Specialty]
NPI: [#]
License #: [#]
Phone: [#]
Fax: [#]
Email (optional): [#]

Attachments (optional):

[Relevant clinical notes/assessment summary]
[Labs/monitoring plan]
[Prior treatment history]

Provider Support Letter: Optional Add-Ons

A: If they're asking for proof of "transition trajectory"

“The patient’s treatment goals are individualized and do not require a predetermined pathway or a commitment to surgery. Non-surgical gender-affirming care is a medically appropriate endpoint for many patients and should be accessible based on current clinical need.”

B: If delay is causing harm (expedited review)

“Delay in treatment is likely to worsen symptoms and increase distress. I am requesting expedited review and timely access to medically necessary care.”

C: If the patient is stable and appropriate for treatment now

“There are no clinical contraindications requiring delay at this time. The patient is appropriate for initiation/continuation of non-surgical gender-affirming care with standard monitoring.”

"Sanctuary" Centers (Common to Aetna, Bupa Global, and Cigna Global

If you are traveling for care, these three locations are the “Gold Standard” where Aetna, Cigna, and Bupa almost always have direct-pay agreements: