Medicare Required to Pay for Sex Reassignment Surgery

Is Transsexual Surgery Medically Necessary?

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Medicare covers a variety of services but until 2014, sex reassignment surgery was not one of them. The U.S. Department of Health and Human Services (HHS) lifted a ban at that time that prevented coverage of these services. Now these surgeries, also referred to as transsexual surgery, transgender surgery or gender-confirming surgery, may be approved on a case by case basis.

The Case of the Purple Heart

Charlene Lauderdale is a former master sergeant in the U.S. Air Force and recipient of the Purple Heart.

She is also a transgender person born with both male and female anatomy. Since 2014, she has been fighting for the right to transsexual surgery.

The Veterans Administration refused to cover the surgery but did offer her hormone therapy. She then sought coverage through her Medicare Advantage plan, a United Healthcare plan. However, her case was denied and brought through several appeals. On Jan. 28, 2016, HHS ruled that United Healthcare had to cover the requested procedure.

What Is Medically Necessary?

Medical necessity is a term you need to understand if you have health insurance. It means that the services requested are an accepted standard of care and are expected to diagnose, treat, or manage a recognized medical condition. Medically necessary services are not experimental. Cosmetic procedures also are not medically necessary.

In the case of Charlene Lauderdale, the question of medical necessity resulted in denials by her Medicare Advantage plan.

However, she had four hospitalizations in 2014 relating to mental health issues. It was determined by HHS that Ms. Lauderdale required transgender surgery as treatment for her underlying gender dysphoria, a condition defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

What This Ruling Means for Transgender Patients

The decision may be appealed by United Healthcare within 30 days of the decision but for now, the decision by HHS to require coverage for transgender surgery may set a new precedent.

It acknowledges that such surgeries are not experimental, not necessarily cosmetic and may constitute a medical need.

The HHS decision could be one that changes how transgender rights are viewed in health care. This is the first time in history that the government has required a private insurer to act in such a capacity. Transgender people who feel they need support may seek assistance from the National Center for Transgender Equality. As in any Medicare case, there may be circumstances that support or weaken a claim. Understanding how the appeals process works may help you to reverse a decision.

Sources:

American Psychiatric Association. Gender Dysphoria.http://www.dsm5.org/documents/gender%20dysphoria%20fact%20sheet.pdf.

Department of Health and Human Services. NCD 140.3, Transsexual Surgery, Docket No. A-13-87, Decision No. 2576. http://www.hhs.gov/dab/decisions/dabdecisions/dab2576.pdf. 

Human Rights Campaign. HHS Rules Transgender Woman Entitled to Surgical Benefits Provided by Medicare Advantage Insurers. https://www.hrc.org/blog/hhs-rules-transgender-woman-entitled-to-surgical-benefits-provided-by-medic. 

National Center for Transgender Equality. Know Your Rights - Medicare. http://www.transequality.org/know-your-rights/medicare. 

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