Index of my related posts: https://www.reddit.com/r/Transgender_Surgeries/comments/revtj4/part_1_penile_preservation_vaginoplasty/

In December, I had penile preservation vaginoplasty with Dr Wittenberg. Before that, though, I had a long fight with insurance to get her covered since she was out of network and there were supposedly in-network options. I was ultimately successful in getting insurance to cover Dr Wittenberg, and my letters were no doubt a part of that. So I want to share what I wrote in the hope that it will help some of you in your own insurance fights.

Dr Wittenberg herself requires three letters: medical clearance, psychiatric clearance, and a letter from your personal mental healthcare provider (for example, a therapist who you have an established relationship with). Since I needed these anyway, I used the same letters to make my case to insurance. The first two were extremely generic boilerplate with very binary language, but for the therapist letter I wrote my own version and my psychiatrist signed it. Additionally, I wrote a cover letter explaining from my perspective why I needed this particular surgery and surgeon.

I want to emphasize that my priority in writing these letters was to get my surgery approved, and so some statements (particularly around preservation of erotic sensation) have...been stretched, and may not align with everyone's experience. Please keep that in mind while reading, especially if you have or want a traditional penile inversion vaginoplasty. Many people have had these procedures and been extremely happy with their results and sensation, and I do not intend to invalidate those experiences. In the end, I had to write what I had to write to have the best chance of approval.

Without further ado, the (redacted) letters:

Cover letter

To whom it may concern,

I am writing to clarify my situation and explain why I am requesting a single case agreement.

I am requesting prior authorization and a single case agreement for gender confirmation surgery with Dr. Heidi Wittenberg (NPI: 1588652143) and Dr. Adam Bonnington (NPI: 1811382328) of MoZaic Care, currently scheduled for December 14, 2021. I have submitted three supporting documents which show medical necessity and capacity to give informed consent (medical; psychiatric; mental health [links to uploaded documents]). Together, these letters satisfy the requirements of the WPATH Standards of Care.

The particular procedure that I will be receiving is a penile preservation vaginoplasty using a peritoneal pull-through technique. This is a unique procedure for two reasons: firstly, the peritoneal pull-through obviates the need for grafting tissue, and secondly, it allows the penis to be preserved, unlike a traditional vaginoplasty.

Dr. Bella Avanessian of Mount Sinai’s CTMS program was recommended by both Oscar and Mount Sinai, but in a pre-consultation visit she stated that she does not use the peritoneal pull-through technique. Instead, Dr. Avanessian harvests the peritoneal tissue and then grafts it to form the vaginal canal. This is a different and inferior technique to the one that Dr. Wittenberg uses. Grafting results in worse vaginal sensation and has a greater risk of tissue necrotizing and other complications. Additionally, Dr. Avanessian does the entire procedure by hand, resulting in a lengthier surgery. Dr. Wittenberg’s technique is done using robotic assistance, which is not only more sophisticated technology but also results in a much shorter surgery, thus minimizing complications.

During the same pre-consultation visit Dr. Avanessian indicated that she has never done a penile-preserving vaginoplasty before, or studied with any surgeon who has. While she is willing to allow me to be her first penile-preservation patient, at this time Dr. Wittenberg has done over thirty such procedures. Dr. Wittenberg has experience and expertise in this particular procedure that no other surgeon in the world possesses.

Penile-preserving vaginoplasty is necessary in my case because a traditional vaginoplasty, which is done by inverting penile tissue, destroys the penis. Gender affirming care is centered around alleviating dysphoria, and in my case, as a non-binary person, removal of the penis would lead to dysphoria. Moreover the traditional penile-inversion vaginoplasty often results in extremely diminished tactile and erotic sensation, whereas penile-preserving vaginoplasty has no impact on penile sensation. Since alternative options to traditional techniques are available, I see no reason to compromise on sensation and alleviation of dysphoria.

To summarize: I am requesting a single case agreement for the penile-preserving vaginoplasty using a peritoneal pull-through technique with Dr. Heidi Wittenberg. This is the only surgeon and the only procedure who is able to meet my needs. Please find attached: a chart of relevant CPT codes and provider information (next page), a copy of my medical clearance letter, a copy of my psychiatric clearance letter, and a copy of my mental health letter.

Sincerely,

Name

[Insurance Company] Member

Mental health letter

To whom it may concern,

I am writing this letter on behalf of Name, who is seeking gender confirmation surgery, specifically Penile Preservation Vaginoplasty.

I am a psychiatrist at Facility Name and have assessed the psychosocial readiness and eligibility, as well as the specific surgical needs, of Name for gender confirmation surgery, specifically Penile Preservation Vaginoplasty. I have worked with Name since 2019 in monthly psychotherapy. Although Name originally sought my care for ADHD management, our sessions have covered a wide range of topics including gender identity, family, employment, friends, and romantic relationships. During the course of treatment, they have been stable and managed their work and personal life. They live their life fully and openly as nonbinary including adopting authentic name and pronouns in all employment and social contexts, with plans for a legal name change once Covid-19 is no longer an obstacle; they have the support of their family, domestic partner, friends, employer, and healthcare providers (List of providers and affiliations) for their pursuit of gender confirmation surgery to align their identity and physical body. Name is deeply involved in and connected to the transgender community.

From a clinical standpoint, I see no valid reason to deny Name's request for gender confirmation surgery (Penile Preservation Vaginoplasty) or to delay it pending further evaluation. Name is diagnosed with gender dysphoria as defined in the ICD-10/DSM-5 (F64.0). The dysphoria that Name currently experiences arises from the incongruence between their body and their gender identity. This results in significant discomfort with their misaligned body. This distress causes Name to experience heightened anxiety, and causes functional interference with their ability to engage in social and interpersonal relationships and activities in a manner that would be expected of any other person at their level of education and position. Rectifying their body incongruence is reasonably expected to provide marked relief for the anxiety and distress that Name experiences, thereby allowing them to live a fully functional and meaningful life in society without further impairments. Name has no history of, nor do they present with, any medical or psychiatric comorbidity that would preclude them from giving informed consent for gender confirmation surgery (Penile Preservation Vaginoplasty).

Name is seeking gender confirmation surgery at this time because it is now feasible both financially and interpersonally through access to health insurance benefits now available to them. Penile Preservation Vaginoplasty specifically is now available medically through the peritoneal pull-through technique, and is offered by Dr. Heidi Wittenberg (MoZaic Care), who has performed more than thirty such procedures. Name has complied with all medical treatment regarding their health care. They have been undergoing medically supervised gender affirming hormone treatments with Dr. Doctor (Affiliation) since January 2020. Name is fully aware of the effects, risk, and consequences of such surgery physically, emotionally, and financially, and they demonstrate ability to make informed healthcare decisions.

Name has transitioned socially and is working towards legal name and gender marker change to reflect their nonbinary identity. Completing this medical procedure (Penile Preservation Vaginoplasty) is the next step in a long, carefully thought out process to achieve physical alignment with their experienced and expressed gender and to resolve their gender dysphoria. It is my clinical opinion that Name is diagnosed with gender dysphoria (F64.0), has exceeded the requirements for the WPATH Standards of Care, version 7, and it is at this time medically necessary for Name to undergo gender confirmation surgery, specifically Penile Preservation Vaginoplasty.

If you have further questions, you may contact me at Phone Number.

Sincerely,

Provider Name, M.D.

Title, Affiliation