The CMS said there's not enough evidence to support Medicare payment for sex change operations. The decision came hours before the Veterans Affairs Department proposed covering sex-reassignment surgeries and other related medical treatment for transgender veterans.
The CMS didn't cover the surgery until 2014, when HHS' Appeals Board struck down a prior national coverage decision forbidding payment. That opened the door for Medicare's regional contractors to allow reimbursement.
In December, the agency announced it was considering a national coverage decision on surgery but now said it has decided the evidence was not there to support the move, according to a proposal released Thursday.
The agency said the clinical evidence was inconclusive for the Medicare population at large. “The low number of clinical studies specifically about Medicare beneficiaries' health outcomes for gender reassignment surgery and small sample sizes inhibited our ability to create clinical appropriateness criteria for cohorts of Medicare beneficiaries,” it said in the notice.
The impact, however, may be more generally felt. While not many seniors pursue sex-change operations, Medicare coverage decisions often influence other payers, experts said. It's estimated that at least 700,000 individuals in the U.S. are transgender, according to federal data. There aren't age-related breakdowns.
Local Medicare administrative contractors, however, can continue to determine coverage on an individual claim basis. The CMS will solicit comments on the rule until July 2. A final decision is expected in the fall.
The proposed decision came hours before the VA said it might begin covering sex-reassignment surgeries and other related medical treatment for transgender veterans.
"Surgical procedures are now widely accepted in the medical community as a medically necessary treatment for gender dysphoria," the Obama administration said in a June 3 notice. "Additionally, recent medical research shows that gender dysphoria is a serious condition that has had severe medical consequences for certain patients if transition-related surgeries and procedures are not provided."
Advocates expressed dismay and confusion over the conflicting decisions, given the CMS reviewed the same studies that the Appeals Board did to reach its decision.
Transgender Medicare beneficiaries “have been waiting their whole lives to have access to this life-saving treatment,” said Anand Kalra, health program manager at the Transgender Law Center. “To have it dangled in front of them, but then for it to remain out of reach is very destructive and dangerous.”
Depression and suicidal thoughts can plague individuals suffering from gender dysphoria, said Daniel Bruner, a senior director of Policy at Whitman-Walker, a Washington, D.C.-based clinic that specializes in LGBT patients. He has seen those symptoms disappear following surgery.
A 2011 survey by the National Center for Transgender Equality and the National Gay and Lesbian Task Force found that 41% of respondents reported suicide attempts—a rate 25 times higher than the general population.
Others argue that the CMS' decision isn't all bad news. “What's really important here is that some Medicare recipients will continue to receive care,” said Jennifer Levi, a lawyer who directs the Transgender Rights Project of Gay & Lesbian Advocates and Defenders. “That's really important because for decades, that wasn't the case.”
The cost for gender reassignment surgery can be as high as $50,000 for women transitioning to men, and $7,000 to $24,000 for men transitioning to women.
The LGBT community has made other gains this year. Last month, HHS finalized a civil rights law to apply to sexual discrimination that includes gender identity. Previously, the rights were limited to discrimination based on race, color, national origin, disability and age.
The rules are expected to significantly change healthcare, from electronic medical records to non-gender assigned facilities.
