Medicare and Osteoporosis Screening for Transgender People

medicare osteoporosis screeening

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With passage of the Affordable Care Act in 2010, many preventive screening services were made free to people on Medicare. Bone scans for osteoporosis, however, are more often covered for women than men. Members of the transgender community may be unclear if they qualify for free screening if they no longer identify with their sex assignment at birth.

This article will discuss when osteoporosis screening is appropriate for trans men and trans women, and how it may be covered under Medicare.

Osteoporosis Screening for Medicare Beneficiaries 

Medicare covers free osteoporosis screening with a bone density test every 24 months for the following:

  • Estrogen-deficient women (e.g., natural or surgical menopausal) who are at risk for osteoporosis
  • Primary hyperparathyroidism
  • Ongoing osteoporosis treatment that requires monitoring
  • Ongoing or planned long-term treatment with steroids (e.g., prednisone)
  • X-rays that show weak/thinning bones or vertebral fractures

Other risk factors for osteoporosis are not specified by Medicare. The U.S. Preventive Services Task Force (USPSTF) also lists excessive alcohol consumption, low body weight, parental hip fractures, previous fractures, rheumatoid arthritis, and smoking as risk factors in its current guidelines.

Keep in mind that the most recent USPSTF recommendations for osteoporosis screening are based on cisgender populations. No formal guidelines have been released regarding transgender individuals.

Recommendations From Transgender Organizations

There is insufficient data to make formal guidelines for osteoporosis screening in transgender people at this time. Until more research is available, consideration must still be made to protect bone health in this population.

Several transgender health organizations have recommended screening for osteoporosis. They encourage screening anyone 65 and older, screening anyone 50 to 64 with risk factors for osteoporosis, and screening at any age for those who have had gonadectomy (removal of the ovaries or testicles) if they have not also had hormone therapy for at least five years.

Medicare may or may not recognize those guidelines. This article focuses on screening from a Medicare perspective and what could potentially be covered as a free test. It is possible that Medicare will cover screening in other situations, but it may require you to pay a 20% Part B coinsurance for the bone scan.

Osteoporosis Screening for Trans Men

The question is whether a trans man, an individual who identifies as male but was assigned female at birth, qualifies for free Medicare screening based on their estrogen deficiency.

Trans Men Without Medical Treatment

A trans man who has not initiated cross-sex hormone therapy and has not undergone gender confirmation surgery would still undergo the physiological changes attributable to menopause. The decrease in estrogen increases bone resorption at a faster rate than bones can form. The resulting bone loss can lead to osteoporosis.

In this case, a trans man is the biologic equivalent to a cisgender woman. Osteoporosis screening is appropriate and should be covered by Medicare.

Trans Men on Hormone Therapy

Some trans men may opt to pursue cross-sex hormone therapy to increase masculine characteristics. This could influence their bone health.

In simple terms, estrogen is essential for building strong cancellous bones (e.g., the vertebra) and cortical bones (e.g., the long bones). Testosterone also plays a direct role in maintaining cancellous bones. Since testosterone can also be converted to estrogen through a process known as aromatization, it also indirectly affects cortical bones.

As long as a transgender man consistently takes testosterone, he is unlikely to face bone losses that could place him at risk for osteoporosis. He is unlikely to qualify for Medicare osteoporosis screening unless he is inconsistent or stops taking testosterone after his ovaries stop working or have been removed. Only then would he be considered estrogen deficient.

Gonadotropin-releasing hormone (GnRH) agonists are hormone treatments used to treat gender dysphoria in children and adolescents. These hormones effectively delay puberty and the development of sex characteristics such as breast development or growth of facial hair.

When these hormones are stopped, puberty resumes. GnRH agonists are also used to treat precocious puberty—that is, puberty that starts at a younger age than expected.

During the time that GnRH agonists are administered, estrogen and testosterone production is decreased. These deficiencies increase the risk of weak bones.

One study showed that the bone density of their spines decreased during treatment for trans boys, but not trans girls. This was stabilized after the initiation of cross-sex hormone replacement.

For trans men, GnRH agonists are not part of the adult regimen. Men who were treated with GnRH agonists as adolescents and proceed with cross-sex hormone replacement may not be considered at increased risk of osteoporosis.

Those who do not proceed with hormone treatment are eligible for Medicare-covered osteoporosis screening once they enter menopause, be it naturally or surgically.

Trans Men After Gender Confirmation Surgery

Gender confirmation surgery is not limited to one procedure. A transgender man could choose to have any of the following procedures:

A transgender man who undergoes gender confirmation surgery with removal of the ovaries has, by definition, undergone surgical menopause. Other gender confirmation procedures do not lead to estrogen deficiency.

If he does not pursue hormone therapy, he is eligible for free Medicare osteoporosis screening. That said, many trans men in this situation will take cross-sex hormones. In that case, testosterone supplementation may be sufficient to maintain healthy bones, and Medicare screening may not be covered as a free service.

Osteoporosis Screening for Trans Women

Trans Women Without Medical Treatment

Interestingly, trans women who are not treated with cross-sex hormones tend to have lower bone density measurements than cisgender men. This has been attributed to decreased physical activity, and may also be due to higher rates of smoking and lower vitamin D levels.

A trans woman who does not seek medical treatment will have natural production of testosterone that will maintain overall bone health. She is the biologic equivalent of a cisgender male. Screening will not be covered for free unless she has other medical conditions that put her at risk for osteoporosis.

Trans Women on Hormone Therapy

A transgender woman may want to pursue hormone treatment to increase feminine characteristics. Cross-sex hormone therapy can be more complicated for trans women than trans men. Not only is there estrogen replacement, but they may also require anti-androgen medication. This may or may not include GnRH agonist treatment.

A transgender woman is not considered estrogen deficient if she is treated with cross-sex hormone replacement, even if she is also on a GnRH agonist. However, if she is treated with a GnRH agonist but does not receive estrogen, her risk is increased, and osteoporosis screening should be pursued.

Trans Women After Gender Confirmation Surgery

Gender confirmation surgery for trans women can include breast augmentation, orchiectomy (removal of the testes), prostatectomy (removal of the prostate), scrotectomy (removal of the scrotum, cannot be performed if a vaginoplasty is planned), or vaginoplasty (formation of a vagina).

A trans woman who undergoes removal of the testes decreases the natural production of testosterone in the body, but undergoing other gender confirmation surgeries does not have the same effect. If she proceeds with estrogen therapy in that case, she does not increase her osteoporosis risk.

If she does not proceed with hormone therapy, however, there will not be adequate estrogen or testosterone to protect the bones. Her osteoporosis screening should be covered by Medicare free of charge.

Legal Gender and Billing

Approximately 1.4 million Americans are transgender, with more than 10,000 on Medicare. Some, but not all, will choose to change their legal gender.

Each state has its own policies when it comes to birth certificates and driver’s licenses. When it comes to passports, the federal government requires a medical certification confirming that a transgender individual is transitioning male to female or female to male.

Medicare approves services based on legal gender. To assure that no one is denied care for services they need, Medicare recognizes two billing codes that address gender discrepancies.

Specifically, the Centers for Medicare & Medicaid Services has designated a condition code 45 (Ambiguous Gender Category) for Part A services and a KX modifier (“requirements specified in the medical policy have been met”) for Part B services. If Medicare denies coverage, reach out to your doctor to make sure they included these billing codes.

Summary

Medicare covers osteoporosis screening for women with estrogen deficiency. What constitutes estrogen deficiency will vary for transgender individuals based on their choice to proceed with cross-sex hormone therapy or gender confirmation surgery. Understanding how these factors work together will assure that people get appropriate osteoporosis screening and that they get it free of charge.

A Word From Verywell

It can be confusing to know whether you are at risk for osteoporosis when you do not identify with the sex assigned at birth. Be sure your healthcare professional knows your medical history for hormone therapy and surgery so they can properly assess your risks.

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