Medicare/Medicaid Reconsidering Whether to Pay for Sex-Change Surgery

Medicare and Medicaid do not pay for sex-change surgery, but that may change.

In response to a formal request from a transsexual woman, the federal Centers for Medicare and Medicaid Services (CMS) announced on March 28 that it has launched a formal "reconsideration" of its current refusal to cover surgical treatment for "gender identity disorder."

The initial 30-day public comment period began Thursday, when the notice was posted.

CMS says it will consider all public comments, and it is particularly interested in clinical studies and other scientific information pertaining to transsexual surgery.

According to CMS, Surgical Treatment for Gender Identity Disorder (formerly referred to as transsexual surgery in chapter 140.3 of the Medicare National Coverage Determinations Manual) is currently not covered under the Medicare Part A and Part B programs.

The existing policy, which became effective in 1981, states that transsexual surgery is considered experimental.

Chapter 140.3 of the coverage manual (revised in October 2003) reads as follows:

Transsexual surgery, also known as sex reassignment surgery or intersex surgery, is the culmination of a series of procedures designed to change the anatomy of transsexuals to conform to their gender identity. Transsexuals are persons with an overwhelming desire to change anatomic sex because of their fixed conviction that they are members of the opposite sex. For the male-to-female, transsexual surgery entails castration, penectomy and vulva-vaginal construction. Surgery for the female-to-male transsexual consists of bilateral mammectomy, hysterectomy and salpingo-oophorectomy which may be followed by phalloplasty and the insertion of testicular prostheses.

Transsexual surgery for sex reassignment of transsexuals is controversial. Because of the lack of well controlled, long term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism, the treatment is considered experimental. Moreover, there is a high rate of serious complications for these surgical procedures. For these reasons, transsexual surgery is not covered.

One formal request to reconsider the denial of coverage came in an Aug. 21, 2012 letter to CMS:

"I am writing to initiate a review of NCD 140.3 Transsexual Surgery," Emily Pittman Newberry wrote in a letter to the CMS Coverage and Analysis Group.

The current determination that such surgery is experimental "is directly contradicted by later studies," Newberry wrote.

Newberry is a poet who writes about her transition from "pretending to be the 'steady freddy' guy everyone thought they knew to the liberated woman, Emily."

In her request to CMS, Newberry quoted the World Professional Association for Transgender Health as saying: "These medical procedures and treatment protocols are not experimental: decades of both clinical experience and medical research show they are essential to achieving well-being for the transsexual patient.”

(CMS received a second letter requesting reconsideration from M’ Nehael Jae Shields, which can be seen here.)

Medicare, which provides health insurance to elderly and disabled people, is funded mostly by payroll taxes and general revenues. Medicaid is funded jointly by the federal government and the states.  CNS