Just Read: Medicare bids farewell to the 20th Century in covering transgender person care, and maybe pokes fun at itself, too…

even assuming the NCD’s exclusion of coverage at the time the NCD was adopted was reasonable, that coverage exclusion is no longer reasonable.

In english, this means that Medicare’s former determination in 1981, 33 years ago, that gender confirmation surgery should not be covered, is now history. Medicare entered the 21st century only 14 years too late. With glass-half-full, that’s 3 years faster than the length of time it takes for science to make it into practice 🙂

Definitively stated: Gender confirmation surgery is safe, effective, backed by science

There is an excellent review of the literature within which puts to rest any notion that gender confirmation surgery is experimental (it isn’t), that there isn’t evidence to support its use (there is, plenty), that it isn’t safe (it is).

The experts cited note that the surgical procedures used in gender confirmation have been validated (and are covered) in other medical conditions, such as Mayer-Rokitansky-Kuster-Hauser syndrome, or MRKH, in which women are born with a complete or partial absence of a vagina, cervix and uterus.

With regard to safety, 1985 appears to be the turning point year, where surgical technique improved to the point that compliation rates and hostpital stay requirements went down significantly.

The decision also points out something that wasn’t called out in 1981, which is the lack of safety in a situation where treatment is not offered:

…(Gender Dysphoria) ..if left untreated, can result in clinically significant psychological distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death”

By the way, all of these symptoms of no treatment, leading up to and including death, are covered in health insurance plans even if the medically necessary care is not. In other words, as stated by the American Medical Association, coverage for this care is probably preventive.

Laughter is good medicine – do I detect a little humor in here?

I assume there are many ways to wipe away a 33 year legacy. You can do it with solemnity but you don’t want to appear too solemn because then the legacy won’t be sufficiently wiped. I suppose you can inject some humor into it as well, and that’s what I spy in this paragraph on page 18:

the 1981 report (and the NCD) cited an alleged “lack of well controlled, long term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism” as a ground for finding the procedures “experimental.”

…and then goes on to say that the same report cited studies that ran in length from 3 months to 13 years and

If these studies do not qualify as acceptable long-term studies, the basis for such a conclusion is not adequately explained in the NCD record.

This is unmistakeable medical speak for “you have got to be kidding.”

What else can I say except, I enjoyed it :). In reality though, a subtle poke at the past helps a new generation of medical professionals tease apart data and bias, which are clearly and transparently wrapped up together in the previous coverage decision. Which is now vaporized.

Health plans are changing their coverage decisions in response

A careful review performed by my digital librarian (Google) shows the impact. Check out the difference in this coverage decision from a large commercial health plan in California, from 2012 to 2014. You can see the edits that move this medically necessary care into the same domain as all other medically necessary care. Check it out.

“Use this page to view details for national coverage determination (ncd) for transsexual surgery (140.3)” – this is the “heritage” coverage determination, which was invalidated on May 25, 2014. (see original)

Fit for the museums of the future…

In addition to saving the coverage decisions above, I’ve also clipped the 1981 National Coverage Decision for posterity. One day it will hang on a museum wall (Perhaps this one? @LGBTMuseum ) where people will stare at it in disbelief.

This saga reminds me of a quote I will never forget by one of my medical school professors, Andrew Weil, MD (yes, that Andrew Weil), who once said, “We’ll look back at what we did to people with cancer in 20 years and be aghast.” Maybe that’s the quote that will be printed on the wall above these heritage pieces as well, and I am so happy to be in medicine on the other side of those 20 years. I only wish we didn’t have to wait so long.

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Congrats, sorry it took so long

Welcome to the present, Medicare, we’re glad to have you!

1 Comment

Ted Eytan, MD