HHS drops Medicare Exclusions for Select Transgender Patient Care

The US Department of Health and Human Services (HHS) ended Medicare exclusions for select transgender patient care.

The HHS Appeals Board decision applies only to gender-confirmation and transition-related surgical procedures:

The Board has determined that the National Coverage Determination (NCD) denying Medicare coverage of all transsexual surgery as a treatment for transsexualism is not valid under the “reasonableness standard” the Board applies […] Since the NCD is no longer valid, its provisions are no longer a valid basis for denying claims for Medicare coverage of transsexual surgery, and local coverage determinations (LCDs) used to adjudicate such claims may not rely on the provisions of the NCD.

Access to transition-related care had been categorically excluded by HHS. This came in stark opposition to standards of care established by the American Medical Association and American Psychological Association. While the decision does not extend to treatments other than gender confirmation surgery, it does represent another case of Medicare approaching modern medical and psychiatric practice.

Successfully challenging the exclusion was a coalition formed by the ACLU, Gay & Lesbian Advocates & Defenders (GLAD), and the National Center for Lesbian Rights. Numerous third-party amicus briefs also helped shape the appeals board’s decision, including those by the Transgender Law Center.

It is consistent with the consensus of the medical and scientific community that access to gender transition-related care is medically necessary for many people with gender dysphoria. The removal of the exclusion of coverage for surgical care for Medicare recipients means that individuals will not automatically have claims of coverage for gender transition-related surgeries denied. They should either get coverage or, at a minimum, receive an individualized review of the medical need for the specific procedure they seek, just like anyone seeking coverage for any other medical treatment.”

Great news: #Medicare to update healthcare standards for #transgender patients, including coverage of surgical care! http://t.co/A7ZJpo0uQD

— GLAD (@GLADLaw) May 30, 2014

The original suit filed sought an administrative appeal on behalf of Denee Mallon, a transgender women and Army veteran who had been denied Medicare coverage in treating gender dysphoria.