Does Medicare Cover Transgender Surgery?
Medicare determines coverage for transgender surgery, also known as gender affirmation surgery, on a case-by-case basis. It has not issued a federal rule for this procedure or for gender dysphoria-related hormone therapy. If your request for this surgery is denied, you can appeal the decision.
What Is Transgender-Related Surgery?
Transgender surgery, also known as sex reassignment or gender affirmation surgery, is one or more surgical procedures in which a transgender person’s physical appearance and function of their sexual organs are altered to resemble those of their identified gender.
Sex reassignment surgeries are typically divided into two broad categories: Top surgeries and bottom surgeries.
- Top Surgeries
- For female to male, top surgery involves removing breast tissue and flattening the chest. For male to female, it involves breast augmentation.
- Bottom Surgeries
- There are multiple types of bottom surgeries. For female to male, phalloplasty and metoidioplasty are used to construct a penis. Other surgeries are used to construct a scrotum. For male to female, vaginoplasty and penile inversion procedures are used to construct a vagina.
These surgeries can be expensive, carry health risks and complications, and may involve follow-up medical care and procedures. Speak with your doctor to learn more and to develop a plan of care.
Many transgender people choose to practice hormone therapy. You may need to do so for your gender affirmation surgery to be considered medically necessary.
- Estrogen Therapy
- This is used for people transitioning from male to female. During feminizing hormone therapy, you are given medication to block testosterone. You are also given estrogen to decrease testosterone production and induce feminine secondary sex characteristics.
- Testosterone Therapy
- This is used for people transitioning from female to male. During masculinizing hormone therapy, you are given testosterone, which suppresses your menstrual cycle and decreases the production of estrogen from your ovaries.
Medicare Coverage of Gender Reassignment Surgery
Medicare did not cover transition-related surgery for many years because it categorized such operations as experimental.
That exclusion was eliminated in 2014.
In 2016, the Centers for Medicare & Medicaid Services, or CMS, decided that local Medicare Administrative Contractors can determine coverage of gender reassignment surgery on a case-by-case basis.
CMS chose not to issue a wider National Coverage Determination for sex reassignment surgery, according to a 2016 decision memo, because the clinical evidence was “inconclusive for the Medicare population.”
Likewise, CMS has not made a National Coverage Determination for gender dysphoria-related hormone therapy or other potential treatments.
Local administrators decide whether to cover gender reassignment surgery based on whether the operation is “reasonable and necessary” for the beneficiary after considering the person’s specific circumstance.
For Medicare Advantage beneficiaries, each Medicare Advantage plan is responsible for determining whether surgery is reasonable and necessary.
Medicare does not cover certain cosmetic surgery procedures, such as laser hair removal and facial feminization surgery, because these are not considered medically necessary.
Determining If a Procedure Is Reasonable and Necessary
According to the CMS decision memo, physician recommendations are one of many potential factors that local Medicare administrators may consider when deciding whether documentation is sufficient to pay a claim.
The best way to find out if your gender affirmation surgery is covered is by speaking with your doctor or Medicare plan provider.
What If Your Surgery Is Denied?
Because transition-related surgery is decided on a case-by-case basis, your request may be denied.
However, if you and your doctor believe the surgery is reasonable or medically necessary, you can appeal Medicare’s decision.
Original Medicare beneficiaries can fill out a Redetermination Request Form to appeal. Medicare has 60 calendar days to respond.
Medicare Advantage beneficiaries must directly contact their plan provider to appeal. Medicare Advantage plans have 30 to 60 calendar days to make a decision on your case.
Organizations such as the National Center for Transgender Equality highly recommend that beneficiaries consult with a lawyer before filing an appeal.
You can appeal Medicare’s decision up to four times after your first appeal.
5 Cited Research Articles
- Mayo Clinic. (2020, April 14). Feminizing hormone therapy. Retrieved from https://www.mayoclinic.org/tests-procedures/feminizing-hormone-therapy/about/pac-20385096
- Mayo Clinic. (2020, April 14). Masculinizing hormone therapy. Retrieved from https://www.mayoclinic.org/tests-procedures/masculinizing-hormone-therapy/about/pac-20385099
- Mayo Clinic. (2017, September 26). Feminizing surgery. Retrieved from https://www.mayoclinic.org/tests-procedures/feminizing-surgery/about/pac-20385102
- Centers for Medicare & Medicaid Services. (2016, August 30). Decision Memo for GENDER Dysphoria and GENDER REASSIGNMENT SURGERY (CAG-00446N). Retrieved from https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=282&CoverageSelection
- National Center for Transgender Equality. (n.d.). What Does Medicare Cover for Transgender People? Retrieved from https://transequality.org/know-your-rights/medicare