Does iliosacral screw removal reduce postoperative pain in unstable pelvic fracture patients? A matched prospective cohort study.

BACKGROUND: To compare pain and function in patients with unstable posterior pelvic fractures stabilized with posterior fixation who undergo iliosacral screw removal versus those who retain their iliosacral screws. METHODS: A prospective observational cohort study identified 59 patients who reported pain at least 4 months after iliosacral screw fixation of an unstable posterior pelvic ring fracture from 2015-2019. The primary intervention was iliosacral screw removal versus a matched iliosacral screw retention control group. Patient-reported pain was measured with the 10-point Brief Pain Inventory, and patient-reported function was measured with the Majeed Pelvic Outcome Score. Both measured within 6 months of the intervention. RESULTS: Before iliosacral screw removal, the mean pain was 4.7 (SD, 3.0) compared with 4.7 (SD, 3.0) in the matched control group. Following iliosacral screw removal, the average pain in the screw removal group was 3.7 (SD, 2.7) and 3.3 (SD, 2.5) in the matched control group. We found no evidence that iliosacral screw removal reduced pain in this population (mean difference, 0.2 points; 95% CI, -1.0 to 1.5; p = 0.71). In addition, the improvement in function after iliosacral screw removal was not statistically indistinguishable from zero (mean difference, 3.1 points; 95% CI, -4.6 to 10.9; p = 0.42). CONCLUSIONS: The results suggest that iliosacral screw removal offers no significant pelvic pain or function benefit when compared with a matched control group. Surgeons should consider these data when managing patients with pelvic pain who are candidates for iliosacral screw removal.

A Review of Insurance Coverage of Gender-Affirming Genital Surgery.

BACKGROUND: Despite the multiple benefits of gender-affirming surgery for treatment of gender dysphoria, research shows that barriers to care still exist. Third-party payers play a pivotal role in enabling access to transition-related care. The authors assessed insurance coverage of genital reconstructive ("bottom") surgery and evaluated the differences between policy criteria and international standards of care. METHODS: A cross-sectional analysis of insurance policies for coverage of bottom surgery was conducted. Insurance companies were selected based on their state enrollment data and market share. A Web-based search and telephone interviews were performed to identify the policies and coverage status. Medical necessity criteria were abstracted from publicly available policies. RESULTS: Fifty-seven insurers met inclusion criteria. Almost one in 10 providers did not hold a favorable policy for bottom surgery. Of the 52 insurers who provided coverage, 17 percent held criteria that matched international recommendations. No single criterion was universally required by insurers. Minimum age and definition of gender dysphoria were the requirements with most variation across policies. Almost one in five insurers used proof of legal name change as a coverage requirement. Ten percent would provide coverage for fertility preservation, while 17 percent would cover reversal of the procedure. CONCLUSIONS: Despite the medical necessity, legislative mandates, and economic benefits, global provision of gender-affirming genital surgery is not in place. Furthermore, there is variable adherence to international standards of care. Use of surplus criteria, such as legal name change, may act as an additional barrier to care even when insurance coverage is provided.

Gender Surgery Beyond Chest and Genitals: Current Insurance Landscape.

BACKGROUND: Plastic surgery plays an essential role in the treatment of gender dysphoria. International standards of care currently consider genital and chest surgeries to be medically necessary. Ancillary procedures such as facial surgery, chondrolaryngoplasty, hair restoration/removal, and body contouring are considered cosmetic surgeries except in individual circumstances. OBJECTIVE: The authors sought to assess the frequency of coverage provision for ancillary transition-related surgeries through a cross-sectional analysis of US insurance policies. METHODS: The authors selected insurance companies based on state enrollment data and market share. Policies were identified through web-based search and telephone interviews. A list of eligible procedures was compiled and grouped into 5 categories: body masculinization, body feminization, facial procedures, hair restoration/removal, and chondrolaryngoplasty. Medical necessity criteria from publicly accessible policies were then abstracted. RESULTS: Sixty-one insurance companies held an established policy. One-third of these policies offered favorable coverage for at least 1 ancillary procedure. Chondrolaryngoplasty was the most covered category (26%, n = 16), whereas body masculinization was the least covered (8%, n = 5). Almost two-thirds of the companies with favorable policies listed coverage criteria. We identified 4 recurring requirements: age, hormone therapy, continuous living in a congruent gender role, and referral from a mental health professional. CONCLUSIONS: There is a low prevalence of US insurance coverage for ancillary gender surgeries and wide variability in coverage criteria. Reevaluation of ancillary transition-related procedures from cosmetic to medically necessary based on clinical judgement or establishment of defined coverage criteria may augment coverage and better address the needs of transgender patients.

Health Insurance Coverage of Gender-Affirming Top Surgery in the United States.

BACKGROUND: Despite the medical necessity, legislative mandates, and economic benefits of gender-affirming surgery, access to treatment remains limited. The World Professional Association for Transgender Health (WPATH) has proposed guidelines for transition-related surgery in conjunction with criteria to delineate medical necessity. The authors assessed insurance coverage of "top" gender-affirming surgery and evaluated the differences between insurance policy criteria and WPATH recommendations. METHODS: The authors conducted a cross-sectional analysis of insurance policies for coverage of top gender-affirming surgery. Insurance companies were selected based on their state enrollment data and market share. A Web-based search and individual telephone interviews were conducted to identify the policy. Medical necessity criteria were abstracted from publicly available policies. RESULTS: Of the 57 insurers evaluated, bilateral mastectomy (transmasculine) was covered by significantly more insurers than breast augmentation (transfeminine) (96 percent versus 68 percent; p < 0.0001). Only 4 percent of companies used WPATH-consistent criteria. No criterion was universally required by insurers. Additional prerequisites for coverage that extended beyond WPATH guidelines for top surgery were continuous living in congruent gender role, two referring mental health professionals, and hormone therapy before surgery. Hormone therapy was required in a significantly higher proportion of transfeminine policies compared with transmasculine policies (90 percent versus 21 percent; p < 0.0001). CONCLUSIONS: In addition to the marked intercompany variation in criteria for insurance coverage that often deviated from WPATH recommendations, there are health care insurers who categorically deny access to top gender-affirming surgery. A greater evidence base is needed to provide further support for the medical necessity criteria in current use.