Sample Referral Letters for Hormone Therapy and Gender-Confirming Surgeries

Often insurance companies who cover hormone replacement therapy and gender-confirming surgeries require a letter from a therapist or a doctor confirming that transgender clients are able to give informed consent about the medical care they are seeking, and/or have fulfilled certain requirements needed before surgery. You may need to provide:

  1. A referral letter from a therapist to an HRT doc
  2. A referral letter from a therapist or HRT doc to gender-confirming surgeon
  3. A letter from a gender-confirming surgeon to your insurance company
  4. Here are some sample letters you may share with your therapists or doctors to follow.

    Sample Therapist Referral Letter for Hormone Replacement Therapy

    [Note the names have been changed to fake names on this form.]

    HRT Referral Letter Example-page-0

    Sample Therapist Letter for Gender-Confirming Surgeries

    Note that per WPATH standards, some gender-confirming surgeries do not require trans people to be on hormones or to have achieved a “social transition” living in their identified gender before some types of surgeries. Talk to your insurance company about what their requirements are so that you can be sure you have met their expectations in order to be covered financially.

    [Name, address, and phone number]

    Dear [Dr. Performing Surgery]:

    [Client name] is a [Client appropriate age] year old [gender identity] transgender individual who has established a longstanding and strong identity as [gender]. [He/She/They] has been on hormones since [date client start HRT or social transition]. [He/She/They] has had [if any previous surgeries put here with dates if no other procedures remove this line]. [He/She/They] is now seeking [name of surgery] to aid in [his, her, their] medical transition.

    [Client name] reports a prior history of anxiety which appears to have been in response to the stressors during [his, her, their] early stages of transitioning. [He/She/They] was entered into therapy in [date client began therapy]. At this time, he presents with no apparent residual psychiatric symptoms and is quite stable. [He/She/They] intends to continue his therapy regime which he believes has been helpful.

    IN THIS PARAGRAPH GIVE SOME DETAIL ABOUT THE CLIENT AS THE EXAMPLE SHOWS:

    [Client name] seems to have significant progress in [his, her, their] transitioning and seems very happy in [his, her, their] decision. [He/She/They] has a strong support system that includes [social description]. [He/She/They] has steady employment that provides his benefits and is attending school for his professional aspirations. His judgment appears sound and good. He has good knowledge of, and had the ability to follow to Standards of Care for surgery.

    I met with [Client name] for an evaluation on [date of evaluation]. I have no hesitation in recommending him for the procedure he has requested. [He/She/They] meets and exceeds the criteria as set forth by the World Professional Association for Transgender Healthcare. If you need any more information or have questions, please do not hesitate to contact me at [therapist phone number].

    Sincerely,

    [Therapist name], [qualifications]

    Sample Letter from HRT or Primary Care Doc to Surgeon for Gender-Confirming Surgeries

    Letter required by Dr. Garramone for gender-confirming surgery.

    http://drgarramone.com/pdf/apsiftmrecommendation.pdf

    Sample Letter from Surgeon to Insurance Company for Gender-Confirming Surgeries

    [Date]
    [Insurance company Address]
    Re: [Patient legal first and last name (AKA preferred name) ]

    To whom it may concern:

    I had the opportunity to see your patient Mr. [Last Name] in my clinic today. Mr. [Last Name] is a __-year-old transgender male who is _’_” tall and weighs ___ pounds. His lifetime highest weight was ___ pounds. He is undergoing a female-to-male gender confirmation (reassignment) process and I understand that he has been taking hormones for [length of time] at this time and has been living exclusively as a male for [length of time). His goal at this time is to undergo the chest reconstruction portion of the gender confirmation and he is aware that the procedure will likely involve an irreversible removal of breast tissue, e.g. a transgender mastectomy with or without free nipple grafting.

    PHYSICAL EXAMINATION: On examination, Mr. [Last Name] has full female breasts which (customize to patient exam:) have a reasonably good degree of symmetry bilaterally. There is moderate ptosis of the nipple on both sides. The breast tissue is relatively well isolated to the central and anterolateral chest area. No breast masses were palpated.

    ASSESSMENT AND PLAN: This patient certainly is an excellent candidate for a transgender mastectomy as part of the integrated process of his gender confirmation. The risks and benefits were discussed extensively with Mr. [Last Name]. He had a significant amount of excellent questions regarding the process and these questions were all addressed. He is aware that he will still need to be monitored for breast cancer during his life, even with the significant removal of breast tissue involved in this procedure. The risks, benefits, incisions and scarring, complications, tradeoffs, recovery, and alternatives were all discussed extensively with the patient. The patient is aware of the possibility of problematic scarring or the loss of a free nipple graft.

    We are therefore requesting insurance approval to make the surgery possible for Mr. [Last Name]. Codes for this procedure are:

    ICD9 – 302.85 GENDER IDENTITY DISORDER IN ADOLESCENTS OR ADULTS

    CPT: 19303 – Simple complete mastectomy, 19350– Nipple reconstruction or 15200 – Full thickness skin graft of the nipples to the chest [note, do not include 19350 or 15200 if keyhole surgery is planned]

    This procedure would be performed on an outpatient basis under general anesthesia.

    Please provide preauthorization for this procedure and we will move forward with Mr. [Last Name]’s surgery.

    Sincerely,
    [Doctor Name]

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