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Cost Coverage
& Application

Your Guide Through
the Bureaucracy Jungle

Don't be afraid of the application. We explain exactly which documents you need for the health insurance company so that your gender-affirming surgery is covered. Step by step.

Cost Coverage -
We Are by Your Side

Gender-affirming surgery (particularly mastectomy/top surgery) is generally a covered service in Germany – provided that the medical necessity has been proven.

Many transgender patients wonder under what conditions the health insurance company covers gender-affirming medical measures and how the application process specifically works. Below you will find an understandable overview of the current legal situation and the procedure with statutory and private health insurance companies.

Statutory Entitlement to Medical Treatment

People with statutory health insurance are generally entitled to medical services if these are necessary to treat an illness or to alleviate significant distress (§ 27 SGB V). There is no fixed catalogue of services for gender-affirming measures. Every requested treatment is examined on a case-by-case basis, whereby the health insurance company assesses whether the measure is adequate, appropriate and medically necessary (§ 12 SGB V).

Gender-affirming measures can fall under this if they contribute to reducing significant distress and other treatment options are not sufficiently effective.

The Path to Cost Coverage by the Health Insurance Company

Application

Psychotherapeutic treatments, aids (e.g. epitheses) as well as gender-affirming surgical procedures must be applied for in advance with the statutory health insurance company. General practitioner services, speech therapy treatments and hormone therapies are generally not subject to application or approval requirements.

An application should be as specific as possible and contain:

  • exact designation of the requested measure
  • place of treatment and practitioner
  • medical documents (e.g. indication letter, medical statements, cost estimates)

Decision Deadlines of the Health Insurance Company

The health insurance company must decide on an application within three weeks.
If the Medical Service (MD) is involved, the deadline is extended to five weeks. The insured persons must be informed of this.

If this deadline is exceeded without sufficient justification, a so-called fictitious approval can occur. In this case, the requested service is considered approved, provided the application was made sufficiently specifically.

Role of the Medical Service (MD)

The health insurance company can commission the Medical Service with a professional examination. The assessment is usually carried out based on the files, without a personal examination.
The assessment serves the health insurance company as a basis for its decision. Insured persons are entitled to receive a complete copy of the MD assessment.

If medical facts are presented incorrectly or incompletely in the assessment, a complaint can be lodged with the Medical Service. This can be done in parallel with an objection.

Checklist:
5 Pillars for Your Application

So that the health insurance company covers the costs, you must submit an application. The insurance company usually forwards this to the MD, which then decides according to the current BGA (assessment guidelines) and S3 guidelines.

These documents must absolutely be included:

1. The Indication Letter & Progress Report (From the Therapist)

The heart of your application. Your psychotherapist confirms the diagnosis "transsexualism" (F64.0)* and that the surgery is medically necessary to alleviate your distress.

2. Medical Findings Report (Gynaecology / Urology / Andrology)

An exclusion of intersexuality. The doctor confirms that everything is physically healthy and that there are no hormonal or genetic reasons for your perception that would speak against surgery.

3. Endocrinology Findings Report (Optional, but recommended)

If you take hormones: A report on your previous hormone therapy. (Note: For the mastectomy, hormone therapy is, according to the guidelines, no longer a mandatory requirement, but is often gladly seen).

4. Trans Curriculum Vitae

A personal report about your background, your feelings since childhood and your distress. Write openly and honestly.

5. The Surgical Information Letter (From us!)

This is where we come in. After your consultation, you receive a detailed doctor's letter. In it, we confirm the diagnosis, provide information about the planned surgical method and justify the medical necessity from a surgical perspective.
* Important: It must state that you have completed at least 6 months of therapy (at least 12 sessions of 50 min each) and that everyday tests in the desired gender role have taken place.
Make an appointment with our experts

Your Roadmap to Cost Approval

  • Collect:
    Obtain all the documents mentioned above.
  • Consultation with us:
    Make your appointment in Bergisch Gladbach. We will create the surgical certificate for you.
  • Submit:
    You write an informal application ("I hereby apply for the cost coverage for...") and send it together with copies of all documents to your health insurance company.
  • Wait & Examination:
    The insurance company (legally speaking) has 3 to 5 weeks to decide, but often involves the MD, which can take longer.
  • The Notice:
    • Approval: Congratulations! Contact us immediately for the surgery appointment.
    • Rejection: Don't panic. Often only small things or wordings are missing. You can lodge an objection. We are happy to look over the rejection.
Double Incision with Free Nipple Grafting

Rejection of the Application: Objection and Lawsuit

Objection Procedure

If the application is rejected, there is the possibility to lodge an objection within one month. The objection procedure is free of charge.
The health insurance company then re-examines the application and has up to three months for this.

If the health insurance company maintains its rejection, it issues an objection notice.

Lawsuit Before the Social Court

A lawsuit can be filed with the competent Social Court against a rejecting objection notice.
The Social Court does not charge court costs. If necessary, legal aid can be applied for. Social court proceedings often take several months and require patience.

Surgical Gender-Affirming Measures

Trans* persons with statutory health insurance can have an entitlement to gender-affirming surgeries if these are medically necessary to reduce significant distress.
In previous case law, it is often required that psychotherapeutic and psychiatric treatment attempts were not sufficiently effective. Surgical procedures are often legally considered a last resort, even though current medical guidelines view psychotherapy as a voluntary offer.

Rejections by health insurance companies are therefore not unusual, but can often be reviewed through objection procedures.

Private Health Insurance and Subsidy

Privately insured persons can additionally turn to the PKV Ombudsman in case of disputes. The procedure is free of charge.
Alternatively, a complaint to the Federal Financial Supervisory Authority (BaFin) is possible.
Civil servants can also have decisions of the subsidy offices reviewed in writing and, if necessary, lodge an objection or file a lawsuit.

Important: Separation of Law and Medicine

The change of first name and civil status is not a prerequisite for medical measures and has no influence on the cost coverage by the health insurance company. Both procedures are legally completely separate.

Our Support

We accompany our patients comprehensively:

  • in the preparation of applications
  • in the compilation of medical documents
  • with queries from the health insurance companies
  • and in the classification of rejections or MD statements

Our goal is a transparent, medically sound and realistic accompaniment through the entire process.

Frequently asked questions about Cost Coverage & Application

We are happy to answer your questions here.

Do I need a new assessment for each surgery?

As a rule, yes. Each gender-affirming measure must be applied for and justified individually. However, your therapist can often build on the existing progress report and supplement it with the specific indication for the new procedure (e.g. correction of the body contour or breast reconstruction).

Will the team at the Transgender Center help me with the application?

Yes. You will receive a detailed surgical information letter (doctor's letter) from us, which explains exactly why the surgery is medically necessary. We know which wordings the MDK pays attention to.

Do I already need to be taking hormones for a mastectomy?

According to the current BGA guidelines (assessment guidelines), hormone therapy is not a mandatory prerequisite for a mastectomy, provided that the medical necessity can be justified in another way. However, many MD assessors like to see hormonal pretreatment as part of the "everyday life test". We will advise you in a personal consultation on how best to document your individual path.

Does the health insurance also cover the costs in a private clinic?

That depends on your insurance status. Private health insurance providers often cover the costs without any problems, depending on the tariff. For those with statutory insurance, coverage of costs in a purely private clinic is usually only possible through the cost reimbursement system (according to § 13 para. 3 SGB V), if no comparable treatment is available in a contracted clinic in a timely manner. We are happy to inform you about the options at our clinic.

What do I need for the application to the health insurance company?

The "Big 5":

  • Indication letter & progress report (therapist)
  • Gynecological/Urological exclusion findings (intersexuality ruled out)
  • Endocrinological findings (hormones, if applicable)
  • Trans curriculum vitae (personally written)
  • Our surgical certificate
What does the mastectomy cost for self-paying patients?

That depends on the effort and the method. After the consultation, we will create a binding complete offer for you, so that you have planning security.

What do I do if my application has been rejected?

A rejection is, first of all, no reason to despair. You have the right to file a written objection within one month. Often, the insurance funds merely request further details or specific wording in the reports. In this case, we are happy to support you with a medical statement to once again substantiate the necessity of the procedure.

Which treatments are normally covered by health insurance?

In Germany, statutory health insurance funds (GKV) generally cover the costs of gender-affirming surgeries that are deemed medically necessary in cases of diagnosed gender dysphoria. These usually include mastectomy, breast augmentation (under certain conditions), as well as gender-affirming genital surgeries. Treatments such as facial feminization surgery (FFS) or permanent hair removal are often decided on a case-by-case basis.

What documents do I need for the application for cost coverage?

For a complete application to the Medical Service (MD), you usually need:

  • A specialist psychiatric or psychotherapeutic indication (confirmation of the diagnosis and necessity of the surgery).
  • A detailed psychiatric/psychotherapeutic progress report.
  • The surgeon's findings report (which you will receive after your consultation with us).
  • A findings report from your endocrinologist (hormone status).
  • A trans-identity CV (this is still requested by some insurance companies, but is legally disputed).
How long does it take for the health insurance company to decide on my application?

Once your application has been received by the health insurance company, it usually has three weeks to make a decision. If the Medical Service (MD) is called in for an assessment, the deadline is extended to five weeks. We recommend always sending the application by registered mail so that you have proof of when it was received.

Do you still have questions?

In our FAQ area we have compiled answers to the most frequently asked questions.

But you are also welcome to contact us very personally. Then we will help you further on an individual basis.

Make an appointment

Get to know us and let yourself be advised without obligation. We clarify all open questions and talk about your desired change.

Completely without compulsion, completely without obligation and above all on equal terms and without prejudice!