Why Sex Therapy & Couples Therapy Aren’t Covered by Insurance—and Why That Might Be a Good Thing
There’s no diagnostic code for loneliness in a marriage.
No CPT billing line for “We haven’t touched in months.”
No reimbursement for the quiet grief of mismatched desire.
And yet, this is what brings many couples to sex therapy or couples therapy—not “mental illness”, but a deep, human need to reconnect, to feel closeness again, to understand what intimacy means in this season of life.
Unfortunately, insurance doesn’t see it that way.
Why Sex Therapy and Couples Therapy Aren’t Covered by Insurance
Health insurance operates on one basic rule: if it’s not medically necessary, it’s not covered. This means a therapist must assign a mental health diagnosis (like major depression or generalized anxiety disorder) to one partner, and the treatment must focus on that diagnosis—not the relationship.
But the essence of couples therapy and sex therapy lies in the relationship itself—the dynamic between two people. Most of the time, no one is mentally ill. There’s just pain, disconnection, resentment, unmet needs, or silence where touch used to be.
Since relationships aren't considered “treatable disorders,” insurance won’t pay for therapy focused on them.
When Billing Insurance Becomes Fraud
Some therapists try to help by assigning a diagnosis to one partner—just to get sessions covered. But this is risky and considered to be insurance fraud.
Here’s why:
The insurance company is being charged for individual treatment of a mental disorder, but the therapist is actually providing couples therapy.
This is a misrepresentation of services—legally and ethically.
Therapists and clients could face legal and financial consequences if the misuse is discovered.
It may seem like a harmless workaround. But it’s not. And it comes with another long-term consequence people rarely talk about……
Diagnoses Follow You—For Life
When you use insurance for therapy, any diagnosis given becomes part of your permanent medical record.
And that can show up in unexpected ways:
Life Insurance: Applications often ask about mental health diagnoses. Having one on record can raise your premiums—or lead to denial of coverage altogether.
Employment: In certain careers—especially those requiring security clearance or mental fitness (military, aviation, law enforcement, legal, tech)—diagnoses can create barriers or red flags.
Professional Licensing: For those in law, medicine, education, or mental health fields, licensing boards may ask about past diagnoses or treatment history.
Immigration & Adoption: A history of mental illness, even inaccurately assigned, can complicate immigration cases or adoption eligibility.
This means that getting a diagnosis for the sake of insurance coverage—when you don’t actually meet criteria—can have lifelong implications.
And let’s be honest, an overzealous or inept therapist could very well provide a diagnosis that is inaccurate. If you paid that therapist through insurance, that misdiagnosis is attached to you for life. It can always be accessed through the national insurance claim database. I advise everyone that asks, when it comes to mental health of any type, pay privately.
Most insurance plans don’t cover sex therapy or couples therapy because they only pay for treatment of a mental health diagnosis in an individual. Therapy focused on relationships, intimacy, or sexual connection usually doesn’t qualify—unless one partner is given a clinical diagnosis, like anxiety or depression.
To fit within the insurance model, therapists are often pressured to assign diagnoses for what are actually normal responses to difficult life situations—like grief, stress, disconnection or relational pain. And with the current breadth of the DSM (Diagnostic and Statistical Manual of Mental Disorders), almost anyone can be diagnosed with something. This turns basic human experience into clinical illness—not because people are disordered, but because the system demands it.
SIDE NOTE: While in grad school, I knew numerous fellow interns that were given the direction to diagnose EVERYONE that walked into the door by the end of the first session to secure insurance billing for the agency or practice. So after 50 minutes of meeting someone, it was mandatory to hastily distill one’s life experience and diagnose every person with a mental illness. I can’t make this up…..
It can also be insurance fraud to bill for couples therapy under an individual diagnosis if the true focus is the relationship. It's not just unethical—it's risky for both client and therapist.
By choosing to pay privately, you avoid these pitfalls and gain:
No diagnostic labels or long-term records
Full confidentiality—your insurance company stays out of your private life
Freedom from insurance restrictions like session limits or provider networks
Honest, ethical therapy that’s truly centered on the relationship
Ultimately, paying privately for sex therapy or couples therapy isn’t just about avoiding red tape—it’s about preserving the dignity of your relationship, and engaging in meaningful work without pathologizing your humanity.
Why Many Sex Therapists & Couples Therapists Don’t Take Insurance At All:
The Risk of Clawbacks
One of the main reasons sex therapists often do not accept insurance is the risk of insurance clawbacks—a little-known but financially dangerous reality in the therapy world.
A clawback happens when an insurance company audits past claims and demands that the therapist repay the money—sometimes months or even years later.
This often occurs when the insurer decides:
The diagnosis wasn't "severe enough"
The documentation didn’t justify “medical necessity”
The therapy was actually relationship-focused (like sex or couples therapy), which the insurance does not cover
Even if the therapist was initially paid for those sessions, the insurer can legally take the money back, leaving the therapist uncompensated for work they already did—possibly years ago.
For sex therapists, this is especially risky because:
Sex therapy and couples therapy are rarely covered by insurance
Assigning a diagnosis just to get coverage can be considered fraud
Even well-intentioned claims can be retroactively denied, years after treatment
Rather than risk financial loss or be forced to pathologize clients to satisfy insurance policies, many sex therapists choose to opt out of insurance entirely—prioritizing ethical care, honest documentation, and a sustainable practice.
The Case for Private Pay: Autonomy and Integrity
Choosing to pay out-of-pocket for sex therapy or couples therapy might seem like a burden at first—but it’s also a powerful act of self-protection and freedom.
Here’s what you gain by avoiding insurance:
No Diagnosis on Your Record
You can work on your relationship without being labeled, coded or tracked….now or later.Deeper Privacy
Insurance companies don’t see your session notes, goals or intimate issues—only you and your therapist do.Honest, Ethical Therapy
No one has to pretend you’re being treated for depression or anxiety when what you really need is help talking about sex after having kids or rebuilding trust after betrayal.Control Over Your Process
Insurance limits sessions, types of therapy and which providers you can see. Private pay puts the timeline and focus back in your hands.
Therapy as an Investment in Meaning, Not Medicine
Sex therapy is not about fixing what’s broken—it’s about tending to what’s important.
Couples therapy isn’t about diagnosing dysfunction—it’s about reclaiming connection, re-learning communication and rewriting your shared story.
If the system can’t understand that, maybe it’s not the system we should let decide.
In a world that wants to medicalize everything, choosing to work outside the insurance model isn’t just practical—it’s existential.
It says:
We are not broken.
We are worthy of care.
And our relationship matters enough to invest in—on our own terms.
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