Medicare Transgender Surgery: What Is (and Is Not) Covered

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Today, more than 1.4 million people identify as transgender, and more than 10,200 of them are on Medicare.

While many people tend to think of Medicare as health care for people over 65, they forget that Medicare also covers younger people with qualifying disabilities. As it turns out, a disproportionate number of transgender Medicare beneficiaries, as many as 77%, are under 65.

Identifying with a gender that differs from the sex assigned to you at birth should not affect your access to health care at any age. Unfortunately, transgender people continue to face healthcare discrimination. Not until 2014 did Medicare offer coverage for transgender surgery, and even now, it remains limited.

The Case That Changed It All

Denee Mallon is a 75-year-old transgender Army veteran. Assigned male at birth but identifying as female, she sought gender confirmation surgery in 2012. Medicare denied her request.

She appealed her case at every level but was refused until she joined forces with the Gay and Lesbian Advocates & Defenders (GLAD), the American Civil Liberties Union (ACLU), and the National Center for Lesbian Rights (NCLR).

When the case was brought to a federal review board in 2014, the Department of Health and Human Services determined that Medicare could no longer categorically deny coverage for gender confirmation surgery.

What Is Transgender Surgery?

Transgender surgery is not one-size-fits-all. One individual’s approach to gender expression may differ from another’s. Surgeries are often grouped into the following categories.

Top Surgeries

Top surgeries are procedures focused on the chest. Trans women (male to female, MTF) may want to increase the size and change the shape of their breasts. Trans men (female to male, FTM) may seek removal of breast tissue for a more masculine appearance.

Bottom Surgeries

These procedures include genital reconstruction and/or removal of the reproductive organs.

For trans men, this may include metoidioplasty (conversion of a clitoris to a phallus), phalloplasty (formation of a penis), testicular implantation, hysterectomy (removal of the uterus), oophorectomy (removal of the ovaries), or vaginectomy (removal of the vagina).

For trans women, this may include vaginoplasty (formation of a vagina), orchiectomy (removal of the testes), prostatectomy (removal of the prostate), or scrotectomy (removal of the scrotum).

Other Surgeries

Gender expression is not limited to the breast, genitals, and reproductive organs. Facial feminization procedures may be considered by trans women to soften more masculine features. For example, the angles of the chin or jaw could be altered or the Adam’s apple could be reduced in size.

Voice surgery procedures may change the pitch of someone’s voice. While a trans man may experience a deeper voice with testosterone, a trans woman is likely to maintain a low pitch while on estrogen therapy.

These are just a few examples of the procedures that may be considered by transgender individuals.

Gender Dysphoria and Medical Necessity

Medicare does not cover any service unless it deems it to be medically necessary. When it comes to gender confirmation surgery, a diagnosis of gender dysphoria is key.

The definition used by Medicare aligns with the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. Gender conformity issues were not introduced until the third edition, DSM-3, in 1980.

At that time, they were referred to as transsexualism. The term evolved to gender identity disorder in the 1994 DSM-4 and to gender dysphoria in the most recent version, DSM-5, released in 2013.

Gender dysphoria occurs when there is an incongruence between someone’s gender identity and/or gender expression that differs from the sex assigned to them at birth. In addition, that incongruence must result in significant psychologic distress that impacts their ability to function in social, occupational, and other settings.

Transgender and Gender Dysphoria

Being transgender is not a mental condition. Not everyone who is transgender has gender dysphoria, and not everyone with gender dysphoria will want to undergo gender confirmation surgery.

While gender confirmation surgery may be medically necessary to treat gender dysphoria, Medicare does not cover what it considers to be cosmetic procedures. There are specific exclusions from coverage for:

  • Blepharoplasty (eyelid surgery)
  • Collagen injections
  • Excision of excess skin
  • Facial feminization procedures
  • Chin or mandible augmentation
  • Hair removal or transplantation
  • Lip reduction or enhancement
  • Liposuction (removal of fat)
  • Mastopexy (breast lift)
  • Rhinoplasty (reshaping of the nose)
  • Rhytidectomy (face lift)
  • Voice modification procedures

National Coverage Determination vs. Local Coverage Determination

Medicare-covered services fall into two discrete categories, those with a national coverage determination (NCD) and those with a local coverage determination (LCD). The former states that the service is covered for all qualifying Medicare beneficiaries nationwide, while the latter allows decisions to be made on a case-by-case basis.

In 1981, Medicare considered transgender surgery to be experimental and excluded it from coverage outright. Simply put, it had neither an LCD nor NCD.

When Denee Mallon won her appeal in 2014, gender confirmation surgery was approved for a local coverage determination. Despite a call for national coverage, the Centers for Medicare & Medicaid Services denied it for an NCD in 2016.

Local coverage determinations require that a Medicare Administrative Contractor (MAC) review each case individually. MACs will vary regionally and may have different requirements. It is important to understand what the MAC in your area requires if you are interested in pursuing gender confirmation surgery.

Requirements for Gender Confirmation Surgery

Medicare has a bare minimum for what is required for coverage of gender confirmation surgery:

  1. You must be at least 18 years old.
  2. You have a diagnosis of gender dysphoria that is chronic or persistent and that meets DSM-5 criteria.
  3. You have participated in psychotherapy for at least 12 months and at a frequency agreed to by you and your healthcare provider.
  4. You have adopted the lifestyle of your desired gender on a full-time, continuous basis for at least 12 months.
  5. Any comorbid mental health or medical conditions are stable.
  6. You provide a letter from a mental health professional that confirms 2–5.
  7. Unless medically contraindicated, you have had 12 continuous months of cross-sex hormone therapy and maintained appropriate medical follow-up.
  8. There is a surgical plan tailored to your specific needs.
  9. You fully understand the risks and benefits of gender confirmation surgery.

Summary

Medicare covers medically necessary gender confirmation surgery for the treatment of gender dysphoria. It does not cover cosmetic procedures. Decisions on whether a beneficiary qualifies are made on a case-by-case basis by the local Medicare Administrative Contractor.

A Word From Verywell

Everyone deserves to feel comfortable in their own body. That has not always been easy for transgender people who want but cannot afford expensive gender confirmation surgery. With Medicare allowing for these surgeries on a case-by-case basis, opportunities are increasing for beneficiaries to get the care and services they need at a reasonable cost.

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Article Sources
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  6. Centers for Medicare & Medicaid Services. Decision memo for gender dysphoria and gender reassignment surgery (CAG-00446N). Published August 30, 2016.