Panel Says Medicare Must Pay for Sex Reassignment

(CN) - Transgender Medicare recipients may no longer be denied coverage for medically necessary sex-change surgeries, which are now safe and effective, a federal review board ruled.

A U.S. Department of Health and Human Services appeals board overturned a rule that banned Medicare coverage for sex reassignment surgeries based on a 1981 report that called such procedures experimental and unsafe.

Denee Mallon, a 74-year-old Army veteran of Albuquerque, N. M., challenged the ban after Medicare refused to cover her genital reconstruction procedures two years ago.

"Sometimes I am asked aren't I too old to have surgery," Mallon told The Associated Press before the board ruled. "My answer is how old is too old? When people ask if I am too old, it feels like they are implying that it's a 'waste of money' to operate at my age. But I could have an active life ahead of me for another 20 years. And I want to spend those years in congruence and not distress."

Experts for Mallon and six advocacy organizations argued that the ban was invalid because the bases for the agency's blanket denial of coverage were not reasonable, given advances in surgical techniques and standards of medical care.

Transsexual surgery, or sex reassignment surgery, refers to a series of procedures designed to change the anatomy of transsexuals to conform to their gender identity. The August 1989 blanket denial of coverage, which relied on the 1981 report, cited a lack of long-term studies on the safety and effectiveness of the procedures as a basis for the decision. The report also said transsexual surgery had a high rate of serious complications.

But Mallon claimed medical studies after 1981 refuted those assumptions.

Physicians and clinical psychologists testifying for Mallon, some of whom had performed thousands of sex reassignment surgeries, said transsexual surgery had become the standard treatment for gender identity disorder, a diagnosed medical condition.

Not only is the procedure safe, it is also the only effective treatment for individuals who suffer from gender dysphoria, an "intense and persistent discomfort with one's primary and secondary sex characteristics - one's birth sex," the experts argued.

Due to advances in surgical technique and medical care, sex reassignment procedures have very few complications, most of which are minor. What's more, the complications that may arise are potential side effects of any type of urogenital surgery covered by Medicare, the physicians testified.

While transsexual surgery may not be appropriate in all cases of transsexualism, treatment needs should be evaluated on a case-by-case basis, according to the experts.

Studies have shown that sex-change surgery reduces depression and suicide rates among people with gender dysphoria, who have reported improved mental health, intimate relationships and self-acceptance after having the surgeries, the physicians said.

After hearing the experts and reviewing the studies, the five-member board agreed that the blanket exclusion was unreasonable in light of the unchallenged medical evidence.

The increasing coverage of sex reassignment surgeries by private and public medical plans and the inclusion of the procedures in prominent surgical text books prove that gender affirming surgeries are no longer experimental or controversial, the board concluded.

"Today's ruling represents the medical community's clear understanding that gender dysphoria is a serious medical condition, and the government should not stand in the way when doctors recommend treatment," National Center for Transgender Equality Executive Director Mara Keisling said in a statement. "This ruling comes from an independent panel who've studied the science on transgender healthcare. Today, this panel ruled that Medicare cannot flat-out exclude medically-supported treatments for transgender people."

The Centers for Medicare and Medicaid Services (CMS), the agency that manages Medicare and makes coverage rules, did not challenge Mallon's experts or evidence.

"The national policy barring Medicare from covering gender transition surgery has been invalidated by HHS's Departmental Appeals Board," a spokesman for CMS said in an email." As with all such determinations, CMS will carry out this independent board's ruling through Medicare Administrative Contractors, who manage Medicare claims payment systems. These contractors may cover this care case-by-case or under a local coverage determination based on clinical evidence to determine medical appropriateness."

The decision does not bar CMS or its contractors from denying individual claims for transsexual surgery for other reasons allowed by law. Decisions on whether or not to cover such care will now be made by Medicare contractors, based on clinical evidence to determine medical appropriateness, a process that is used for most covered services.

The ruling, which must be implemented within 30 days, is binding on the Department of Health and Human Services unless appealed in Federal Court. It does not apply to Medicaid, which provides health coverage for individuals and families with low incomes and is regulated by the states. Some states have blanket exclusions on sex reassignment surgeries and the sex hormones transgender people often take during their transitions, while others evaluate claims on a case-by-case basis.

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