Medicare Now Covering Sex-Reassignment Surgery for Seniors

By Zoey DiMauro | June 4, 2014 | 3:58 PM EDT


Denee Mallon, a 74-year-old Army veteran who challenged Medicare's denial of coverage for his sex reassignment surgery. (AP photo)

( -- Medicare contractors now have the discretion to decide whether to cover sex reassignment surgeries for transgender seniors, according to a final May 30 decision by the U.S. Department of Health and Human Services’ independent Appeals Board. (See Transsexual Surgery.pdf)

The ruling is binding and can only be appealed in federal court.

“It has been repeatedly demonstrated that sex reassignment surgery is safe, effective, and indisputably necessary treatment for certain individuals with severe gender identity disorder,” the board's ruling said.

The recent decision was the result of an administrative challenge filed by several LGBT rights groups on behalf of Denee Mallon, a 74-year-old former forensics investigator who wanted Medicare to cover the costs of his transition from male to female.

Mallon, an Army veteran, was diagnosed in mid-life with gender dysphoria,  which is defined by the American Psychiatric Association as a “strong desire to be treated as the other gender or to be rid of one's sex characteristics.”

“Sometimes I am asked aren’t I too old to have surgery. My answer is how old is too old?” Mallon, who lives as a woman in Albuquerque, N.M. told the Associated Press in an email interview. “When people ask if I am too old, it feels like they are implying that it’s a ‘waste of money’ to operate at my age. But I could have an active life ahead of me for another 20 years. And I want to spend those years in congruence and not distress.”

The ruling upended a 33-year ban on coverage of such surgery, which was deemed experimental due to “the lack of well-controlled, long-term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism.”

But the panel said that “new evidence…outweighs the NCD [previous national coverage determination] record and demonstrates that transsexual surgery is safe and effective and not experimental,” rendering the exclusion of coverage “not reasonable.”

The new guidelines do not guarantee coverage of sex-reassignment surgery, which can cost as much as $50,000.  Rather, “Medicare’s contractors will make determinations case-by-case or through local coverage determinations based on clinical evidence to determine medical appropriateness,” said a spokesman from the Centers for Medicare and Medicaid Services (CMS).

The American Psychological Association says that it is “difficult to accurately estimate the number of transgender people,” making it hard to assess the financial effect of lifting the ban.

According to one insurance company, some steps to qualify for the surgery include a referral from a doctor, time on hormone therapy and experience living as the opposite gender.

The American Civil Liberties Union, Gay & Lesbian Advocates & Defenders, and National Center for Lesbian Rights all hailed the decision as a step towards equality for transgender individuals.

“[Transgender people] should either get coverage or, at a minimum, receive an individualized review of the medical need for the specific procedure they seek, just like anyone seeking coverage for any other medical treatment,” they said in a joint statement.

The LGBT Rights Director for Human Rights Watch, Graeme Reid, called the ruling “a significant victory,” which “removes a tremendous barrier that for years had denied transgender people the right to make decisions about their own bodies.”