SAN FRANCISCO — Medicare can no longer automatically deny coverage requests for sex-reassignment surgeries, a federal board ruled Friday in a groundbreaking decision that recognizes the procedures are medically necessary for some people who don’t identify with their biological sex.
Ruling in favor of a 74-year-old transgender Army veteran whose request to have Medicare pay for her genital reconstruction was denied two years ago, a U.S. Department of Health and Human Services (HHS) review board said there was no justification for a 33-year-old agency rule excluding such surgeries from treatments covered by the national health program for the elderly and disabled.
“Sometimes I am asked, aren’t I too old to have surgery. My answer is, how old is too old?” the veteran, Denee Mallon, of Albuquerque, N.M., 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.”
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Mallon was born a male and has lived as a woman on and off since she was a teenager and full time since 2009.
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 will be able to seek authorization by submitting documentation from a doctor and mental-health professionals stating that surgery is recommended in their individual case, Levi said.
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 UCLA, has estimated that people who self-identify as transgender make up 0.3 percent of the U.S. adult population. More than 49 million Americans are enrolled in Medicare.
The cost of gender-reassignment surgery varies, but typically ranges from $7,000 to $50,000, according to the Transgender Law Center in Oakland, Calif.
In its ruling, the appeals board said HHS lacked sufficient evidence in 1981 when it made a “national coverage determination,” or NCD, holding that Medicare recipients were ineligible for what it then called “transsexual surgery” because the procedure was too controversial, experimental and medically risky.
The panel went on to say that regardless of what the record showed then, studies and experts have since shown the efficacy of surgical interventions as a treatment for gender dysphoria, the diagnosis given to people who experience extreme distress due to the disconnect between their birth sex and their gender identity.
The ruling does not apply to Medicaid, which provides health coverage for individuals and families with low incomes and is regulated by the states.
Transgender-health advocates said that because private insurance companies and Medicaid programs often take their cues from the federal government, the decision could pave the way for sex-reassignment surgeries to be a routinely covered benefit.
The Centers for Medicare and Medicaid Services must eliminate its blanket exclusion on transition-related surgeries within 30 days and re-evaluate Mallon’s medical claim in light of the change, the HHS board said.
“This decision means so much to me and to many other transgender people. I am relieved to know that my doctor and I can now address my medical needs, just as other patients and doctors do,” Mallon said Friday.