Does Medicare Cover Gender-Confirmation Surgery?

Gender-confirmation surgery, also known as 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.

According to a 2022 article from the National Library of Medicine, gender-confirmation surgery has been increasingly performed over the last five years, and has been shown to improve quality of life for those experiencing gender dysphoria.

Gender-confirmation surgeries are typically divided into two broad categories: Top surgeries and bottom surgeries.

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-confirmation surgery to be considered medically necessary.

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-confirmation surgery on a case-by-case basis.

CMS chose not to issue a wider National Coverage Determination for gender-confirmation 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-confirmation 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.

Even if Medicare covers your gender-affirmation surgery, you will still face out-of-pocket costs, such as deductibles and coinsurance payments.

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-confirmation surgery is covered is by speaking with your doctor or Medicare plan provider.

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.