Medicare asked to reconsider coverage of sex reassignment surgery
Published On: 4/3/2013 4:29:34 PM
BY ALICIA AULT
IMNG Medical News
http://www.imng.com
Breaking News
Several organizations representing gay, lesbian, and transgender
people have filed an administrative challenge seeking to overturn
Medicare's 32-year-old prohibition on coverage of sex reassignment
surgery.
"This administrative challenge is being considered and working
its way through the proper administrative channels," a spokesman
for the Centers for Medicare and Medicaid Services said.
The American Civil
Liberties Union, Gay & Lesbian Advocates &
Defenders, the National Center for Lesbian Rights, and civil
rights attorney Mary Lou Boelcke filed the challenge on March 26 on
behalf of Denee Mallon, "a transgender woman whose doctors have
recommended surgery to alleviate her severe gender dysphoria,"
according to a statement.
"Medicare's categorical exclusion of this care lacks any
scientific basis," said NCLR legal director Shannon Minter, in the
statement. "Study after study has shown that these surgeries are
the only effective treatment for many patients suffering from
severe gender dysphoria."
Joshua Block, a staff attorney with the ACLU Lesbian Gay
Bisexual Transgender Project, noted that "the American Medical
Association, the Endocrine Society, and the American Psychological
Society all support these treatments for transgender patients." He
added, "These procedures have been performed for decades and are
proven to be safe and effective."
The AMA House of Delegates adopted a resolution in 2008 advocating private and
public health insurance coverage for treatment of gender identity
disorder, as recommended by a physician. The American Psychological
Association's Council of Representatives adopted a policy statement the same year that, among
other things, advocated adequate mental and physical health care
for transgender and gender variant individuals. The Endocrine
Society approved guidelines for transgender care in 2009.
In 2012, the American Psychiatric Association's Assembly
approved a new policy backing public and private
insurance coverage of gender transition treatment, and opposing
exclusions for medically necessary treatment for transgender and
gender variant people.
Kenneth Zucker, Ph.D., chair of the DSM-5 Workgroup on Sexual and Gender Identity
Disorders, said in an interview that "there's considerable evidence
that hormonal therapy and sex reassignment surgery is often the
treatment of choice for adults with gender dysphoria who are
carefully assessed." Dr. Zucker, psychologist in chief at the
Centre for Addiction and Mental Health in Toronto, called that
"beyond debate." The DSM-5, which is to be published in mid-May,
will include gender dysphoria as a diagnosis.
But Dr. Zucker said that a diagnosis does not dictate the best
practice or treatment for any individual patient. He added that
gender dysphoria had existed as a diagnosis since the DSM-III was
published in 1980; however, it previously was known by other
terms.
Surgical and other medical treatment of gender dysphoria has
lagged in the United States primarily because of a lack of
insurance coverage, Dr. Zucker said.
"If Medicare endorses sex reassignment surgery as a treatment
option for carefully evaluated patients and this was then taken up
and supported by more private insurers, this would reduce barriers
to care," he said.
"A decision by Medicare that this treatment is medically
necessary and not experimental could impact other health coverage
of this surgery," agreed Dr. Dan Karasic, clinical professor of
psychiatry at the University of California, San Francisco. He said
a Medicare policy change could benefit some, including those who
are disabled by HIV or mental illness, and elderly patients with
gender dysphoria. "The clear preponderance of the evidence and
consensus of experts supports the medical necessity of surgical
treatment for gender dysphoria," Dr. Karasic said in an
interview.
Treatment for the gender dysphoria is covered in many countries
with national health systems including the Netherlands, Belgium,
and the United Kingdom, Dr. Zucker said.
Mr. Block of the ACLU notes that California, Oregon, the
District of Columbia, and Colorado have issued regulations
clarifying that private insurers cannot exclude transition-related
health care from their coverage.
According to the Human Rights Campaign's Corporate Equality Index, only 25% of Fortune
500 companies currently offer transgender inclusive health
benefits. That is defined as equal health coverage for transgender
individuals without exclusion for medically necessary care, without
blanket exclusions, and based on the World Professional Association
for Transgender Health Standards of Care.
The administrative challenge was filed with the departmental appeals
board of the U.S. Health and Human Services department. Mr.
Block of the ACLU said that the board will first weigh the evidence
that was used to make the initial coverage decision in 1981. If it
finds that the decision was not properly supported - or that
developments have called into question the reasonableness of the
decision - it will consider new evidence. The ACLU-led complaint
included an expert declaration "that collects the contemporary
evidence to show the national coverage decision lacks any
scientific basis," Mr. Block said.
There appears to be no time limit on when the Appeals Board must
make a decision, he said.
Coincidentally, the administration challenge was filed the same
week that the CMS posted a notice that it would reopen its national
coverage decision on sex reassignment surgery, which has been in
place since 1981. The notice was subsequently removed.
"In light of the challenge, we are no longer reopening the
national coverage determination for reconsideration," a CMS
spokesman said.
Brian Moulton, legal director of the Human Rights Campaign,
applauded the challenge.
"Regardless of the mechanism, we are pleased that CMS will be
reviewing its outdated policy with regard to treatment related to
gender transition and hope they will follow the mainstream medical
opinion that public and private insurance programs should provide
coverage for this medically necessary care," he said.
aault@frontlinemedcom.com
On Twitter @aliciaault
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top_stories; mental_health; general_primary; endocrinology;