Medicare and Cancer Screening in the Transgender Community

Most cancer screening tests are free for Medicare beneficiaries as long as their doctor accepts assignment. Certain cancers, however, are gender-specific based on anatomy. Cervical, ovarian, and uterine cancers are commonly referred to as female cancers, while prostate and testicular cancers are perceived as male. 

Depending on their sex assignment at birth, a transgender individual’s decision to pursue cross-sex hormone therapy and/or gender confirmation surgery could affect whether or not they qualify for certain cancer screening tests. It is important to understand what Medicare services are covered and when.

Legal Gender Designation

Approximately 1.4 million Americans are transgender, and more than 10,000 of them are on Medicare. Some may choose to change their gender on legal documents such as their birth certificate, driver’s license, or passport.

A legal change in gender could affect what Medicare pays for, even when those services are appropriate based on their medical history. Proper billing by a healthcare provider can decrease any inappropriate denials.

The Centers for Medicare and Medicaid Services has designated two billing codes to notify Medicare of differences in gender that affect coverage. For Part A services, condition code 45 should be used. This denotes an Ambiguous Gender Category where services are covered based on a specific gender.

For Part B services, a KX modifier notes that “requirements specified in the medical policy have been met.” This makes clear to Medicare that the provider has considered their patient’s circumstances and sees the service as medically necessary.

Breast Cancer Screening

Female breast cancer accounts for 14.8% of all new cancer cases. It affects 12.5% of women in their lifetime, but men can develop it too. As many as 2,650 men are diagnosed with invasive breast cancer each year.

This is not surprising when you realize that only 80% of invasive breast cancers are estrogen-receptor positive, meaning they grow more aggressively in the presence of estrogen.

Both men and women have breast tissue, and whether or not estrogen is present, there are risk factors that can increase the growth of this tissue. Genetic mutations, for example, account for as many as 5% to 10% of cancer cases.

Medicare covers free breast cancer screening for women only and limits this to a mammogram every 12 months. Ultrasound, magnetic resonance imaging (MRI), and other breast imaging techniques may be covered if there is a medical reason, but they would not be free.

Women should expect to pay a 20% Part B coinsurance for those. Men would pay the coinsurance for all screening tests.

One study showed that trans women on estrogen therapy have an increased risk of breast cancer compared with cisgender men but a lower risk than cisgender women. While there were few cases of invasive breast cancer in trans men, they occurred with or without a previous mastectomy. Again, these diagnoses were less common than in cisgender women.

Fenway Health, an LGBTQIA+ healthcare, research, and education institution, recommends screening for breast cancer for people with breasts and people on five years or more of estrogen hormone therapy.

Billing according to the gender of coverage is the best way to get the mammogram covered. Anyone with a legal gender of female should be billed in the usual manner, i.e., without a condition code 45 or KX modifier.

For people with a legal gender of male, only trans women would qualify for coverage. In that case, billing modifiers should be used.

Cervical Cancer Screening

With the advent of Pap smears, cervical cancer has become far less common, accounting for only 0.8% of all cancer cases in the United States each year. Only 0.6% of women will be diagnosed with this type of cancer in their lifetime.

Medicare covers cervical cancer screening with Pap smear every 24 months for people at average risk. For women at high risk of cervical cancer or women of childbearing age who have had an abnormal Pap smear within the past 36 months, Pap smears are covered every 12 months. Women may also qualify for human papillomavirus (HPV) screening every five years between the ages of 30 and 65.

Medicare does not specify what constitutes “high risk,” but the American Cancer Society highlights HPV infection, chlamydia infection, a diet low in fruits and vegetables, long-standing use of birth control pills, multiple pregnancies, multiple sexual partners, sexual partners with high-risk behaviors, smoking, a weak immune system (including having HIV or being on a medication that suppresses the immune system), and young age at first intercourse or first term pregnancy.

A trans man will remain at risk for cervical cancer unless he has a hysterectomy with removal of the cervix. Screening should be pursued at the recommended intervals.

Ovarian Cancer Screening

Ovarian cancer represents 1.1% of all cancer diagnoses, affecting 1.2% of women over their lifetime. It can be difficult to detect in its early stages, and routine screening is not recommended by Medicare. Instead, an evaluation is pursued only after symptoms develop.

Unfortunately, ovarian cancer can often be insidious, with few to no symptoms early on. Symptoms to watch for include abdominal bloating/fullness, feeling full rapidly when eating, pelvic pain, urinary frequency, or weight loss.

Trans men who have not had the ovaries removed should monitor for these symptoms and bring them to the attention of their doctor.

Prostate Cancer Screening

Prostate cancer accounts for 13.1% of cancers. Although 12.5% of men will be diagnosed with prostate cancer in their lifetime, few men die from it. The five-year survival rate is an impressive 97.5%.

Medicare covers free prostate-specific antigen (PSA) screening once per year but requires a 20% Part B coinsurance for an annual digital rectal exam. Men can choose one or both testing options.

A trans woman is at increased risk for prostate cancer if the prostate has not been surgically removed. Even if she takes estrogen as cross-sex hormone therapy, she would have been exposed to testosterone for a number of years prior to that and this could increase her risk of developing cancer later in life. 

Testicular Cancer Screening

Testicular cancer is relatively uncommon, representing only 0.5% of all cancer cases in the United States. Younger men are usually affected, with the average age of diagnosis at 33 years. Medicare does not currently recommend routine screening.

A trans woman who has not had the testes removed, whether or not she is on estrogen therapy, could be at risk for testicular cancer based on her past years of natural testosterone exposure.

Likewise, a trans man who has had testicular implants should pay attention to their body. They should seek evaluation with a healthcare professional if there are changes to the testes, including increases in size, palpable lumps, swelling, or tenderness.

Uterine Cancer Screening

Uterine cancer accounts for 3.5% of all cancer cases and affects 3.1% of women in their lifetime. Medicare does not recommend routine screening.

A diagnostic evaluation is advised if there are concerning symptoms that could be attributable to cancer. This may include abnormal vaginal bleeding (especially after menopause) or pelvic pain.

A trans man who has not had a hysterectomy should monitor for these symptoms and seek an evaluation as appropriate.

Summary

Medicare recognizes that transgender individuals may qualify for cancer screenings that do not match their legal gender. It has provided billing codes to address these issues to decrease inappropriate denials. Screening for breast, cervical, or prostate cancer should be covered if appropriate for a person's medical and surgical history.

A Word From Verywell

It may be confusing to figure out which cancer screenings are appropriate for a person who does not identify with the sex assigned at birth. Discuss your risks with your healthcare professional. No one should hesitate to get the screening they need out of concern for cost.