US program ends ban on sex-change surgery coverage

May 30, 2014 by Lisa Leff

Transgender people enrolled in the U.S. health program for the elderly and disabled can no longer be automatically denied coverage for sex reassignment surgeries, a Department of Health and Services review board ruled Friday. The groundbreaking decision recognizes the procedures as a medically necessary and effective treatment for individuals who do not identify with their biological sex.

Ruling in favor of a 74-year-old Army veteran whose request to have Medicare pay for her genital reconstruction was denied two years ago, the agency's Departmental Appeals Board ruled that a three-decade-old rule excluding such surgeries from the procedures covered by the program was unjustified.

"Sometimes I am asked aren't I too old to have surgery. My answer is how old is too old?" the veteran, Denee Mallon, said in an email interview before the board issued its decision. "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."

Jennifer Levi, a lawyer who directs the Transgender Rights Project of Gay & Lesbian Advocates and Defenders in Boston, said the ruling does not mean Medicare recipients are necessarily entitled to have sex reassignment surgery paid for by the government.

Instead, the lifting of the coverage ban means they now will be able to seek authorization by submitting documentation from a doctor and stating that surgery is medically indicated in their individual case, Levi said.

"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," Levi's organization said in a statement after the ruling was issued.

Transgender advocates said that because private insurance companies and state-run Medicaid programs that provide for low-income individuals often take their cue from the federal government on which treatments to approve or exclude, the decision could eventually pave the way for sex-reassignment surgeries to be a routinely covered benefit.

No statistics exist on how many people might be affected by the decision. Gary Gates, a demographer with The Williams Institute, a think tank on LGBT issues based at the University of California, Los Angeles, has estimated that people who self-identify as transgender make up 0.3 percent of the U.S. adult population. Over 49 million Americans are enrolled in Medicare.

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