# A National Ambulatory Surgery Sample Cost Analysis of Outpatient Facial Feminization Surgery

## TL;DR

This study examines the costs and insurance coverage of outpatient facial feminization surgery in the U.S., showing that self-payers face the highest expenses.

## Contribution

The study is the first to analyze total charges and payer distributions for outpatient facial feminization surgery using a national database.

## Key findings

- Self-payers incurred the highest median charges for outpatient facial feminization surgery.
- Rhinoplasty and brow lifts were the most common procedures, with significant cost variations by payer type.
- Charges varied significantly by income and geographic location, with higher costs in central metropolitan areas.

## Abstract

Introduction: Facial feminization surgery (FFS) alleviates gender dysphoria, but insurance coverage is minimal and underreported. This study analyzes total charges and primary payer distributions for outpatient FFS care using a national database.

Materials and methods: Data from the 2017-2018 National Ambulatory Surgery Sample were analyzed to identify transgender patients undergoing FFS using ICD-10 and CPT codes. Demographics, surgery center location, and total charges were stratified by procedure and primary payer type and compared using descriptive statistics.

Results: A total of 3,359 encounters were identified with a median patient age of 42 years and a median (interquartile range) charge of $24,679 ($15,716, $39,442). Private insurance was the most common payer (N=1657, 50%), followed by self-payers (N=667, 20%), Medicare (N=540, 16%), and Medicaid (N=286, 8.3%). Median costs were highest for self-payers ($27,736 ($17,392, $39,385)), followed by private insurance ($26,989 ($17,798, $44,933)) and Medicaid ($26,968 ($16,756, $46,467)). Medicare had the lowest median charge ($17,467 ($10,322, $29,210)). Charges differed significantly by income (p<0.001) and location (p<0.001), with higher earners and central metropolitan areas incurring the highest costs ($25,249 and $26,782, respectively). Rhinoplasty (N=1990, 59%) and brow lifts (N=363, 11%) were the most common procedures. Brow lifts had the lowest median cost ($11,834 ($8,366, $18,317)) and were most often covered by Medicare (N=217, 60%). The total charges for rhinoplasty were $23,050, with private insurance as the primary payer (N=1017, 51%).

Conclusions: This study is the first to characterize total charges and payer distributions for outpatient FFS. This broad analysis highlights the significant financial burden of FFS, especially on self-paying patients.