Sex Therapy, Insurance, and Medical Necessity: What It All Really Means
If you’ve ever looked into sex therapy, you may have heard phrases like “medical necessity,” “primary diagnosis,” or “secondary diagnosis” and thought… what does that actually mean for me?
You’re not alone. Insurance rules around sex therapy can feel confusing and even frustrating. The good news is that once you understand the basics, it’s much easier to see why insurance sometimes applies, and why private pay is sometimes required.
Let’s walk through it in everyday language.
What “Medical Necessity” Really Means
Insurance companies only pay for therapy when they believe it is medically necessary. That doesn’t mean something is “wrong” with you it just simply means:
The therapy is needed to treat a mental health condition that causes real distress or affects daily functioning.
Insurance does not pay for therapy just because something could be improved or explored. It pays when therapy is treating a problem that meets their medical rules.
So the key question insurance asks is:
“What mental health condition are we treating?”
Primary Diagnosis: The Main Reason Insurance Pays
A primary diagnosis is the main mental health condition insurance recognizes as the reason for treatment.
Think of it as:
“This is the main issue therapy is focused on right now.”
Common primary diagnoses that insurance may cover include:
Anxiety
Depression
PTSD or trauma-related conditions
Adjustment stress
Relationship distress (with limits, depending on the plan)
If sex or intimacy issues are connected to one of these conditions, insurance may apply.
Example:
Someone comes to therapy because anxiety is making sex stressful and avoidant.
Primary diagnosis: Anxiety
Sex therapy work: Part of treating anxiety
Insurance: May cover sessions
Secondary Diagnosis: Important, But Not the Billing Focus
A secondary diagnosis is something that is also being worked on, but it’s not the main reason insurance is paying.
This often includes:
Intimacy or communication struggles
Relationship stress related to sex
Insurance may allow these topics to be addressed as long as the primary diagnosis is driving treatment.
Example:
Someone is being treated for depression, and low desire is one of the symptoms.
Primary diagnosis: Depression
Secondary concern: Low sexual desire
Insurance: May cover because depression is the treatment priority. However, this also means its the focus of why a person is attending therapy.
Treatment Priorities: Why This Matters
Insurance expects therapists to focus treatment on the primary diagnosis first.
That means:
Sessions must support improvement in the primary mental health condition
Sex-related concerns must be connected back to that condition (meaning our work, if successful, lowers a clients depression and improves the sex-related concern)
The therapist documents progress toward mental health goals
If the main focus becomes sexual growth, pleasure, or relationship enhancement without a mental health condition driving it, insurance usually stops applying.
When Sex Therapy Is Often Private Pay
Sex therapy is usually private pay when:
There is no mental health diagnosis
Focused on aspects of pleasure improvements
The concern is about improving intimacy, desire, or pleasure
The client does not want a diagnosis on record
The work is educational, exploratory, or wellness-focused
Couples want balanced care without labeling one partner as the “patient”
Example:
A couple wants to reconnect sexually and improve communication, but neither partner has a diagnosable condition that is impacting their sex life (e.g. Erectile dysfunction experienced due to Depression), or their communication.
Medical necessity: No (by insurance standards)
Payment: Private payThis doesn’t mean the work isn’t valuable. It just means insurance doesn’t classify it as medical treatment.
Sex Therapy Insurance Coverage in Maryland, Virginia, and Texas
Healing Intimacies provides sex therapy services to clients in Maryland (MD), Virginia (VA), and Texas (TX). Insurance coverage and private pay options vary by state, provider licensing, and individual insurance plans.
In all three states, insurance may apply when:
Therapy is medically necessary
A primary mental health diagnosis is identified
Sex and intimacy concerns are addressed as secondary treatment goals
Private pay options are also available for clients seeking sexual wellness, relationship enrichment, or diagnosis-free care. We believe in transparent conversations about payment so clients can make informed choices about their care.
If you are located in MD, VA, or TX and have questions about sex therapy, insurance, or private pay options, we encourage you to reach out directly for personalized guidance.
Why Therapists Sometimes Recommend Private Pay
Private pay allows therapy to be:
More flexible
More holistic
Less focused on labeling
More centered on growth, pleasure, and connection
Free from insurance session limits and restrictions
In sex therapy especially, private pay can prevent normal sexual differences from being treated like medical problems.
How to Know What Applies to You
When starting sex therapy, it’s okay to ask:
Will insurance apply in my situation?
What would be the primary diagnosis?
What would be considered secondary concerns?
What parts of therapy would be private pay?
Can I switch later if my needs change?
A transparent therapist will explain this clearly and help you decide what feels right.
The Takeaway
Here’s the simple version:
Insurance pays when sex therapy is part of treating a recognized mental health condition (primary diagnosis).
Sex and intimacy concerns can be worked on as secondary issues if they connect to that condition.
Private pay is common when therapy focuses on sexual wellness, relationship growth, or exploration without a diagnosis.
Both paths are valid. The most important thing is getting care that feels supportive, respectful, and aligned with your goals. Not just what insurance prefers.
If you want to start therapy with Healing Intimacies today please reach out here and let’s continue this conversation in your free fifteen minute consultation!