- The staggering costs of being transgender in the US, where even patients with health insurance can face six-figure bills
- Medical procedures are often essential, but they come at a cost
- Trans-related surgeries can cost tens of thousands of dollars, yet insurance companies don't always cover them
- Gaps in insurance coverage persist
- Defining what's 'medically necessary'
- 'Cis guys don't have to pay for their penises'
- The high cost of being transgender
- The surgery: What does it cost?
- Insurance and surgery
- The costs of not transitioning
- Medicare for transgender-related health care
- Does Medicare cover hormone therapy?
- Does Medicare cover transgender surgery?
- Transgender Health Benefits
- Is treatment considered «Medically Necessary?»
The staggering costs of being transgender in the US, where even patients with health insurance can face six-figure bills
In the past six years, Claire, an IT infrastructure engineer living in New York, has spent thousands of dollars on medical care that most Americans never have to think about. There was hormone therapy, hair removal, and what's known as «bottom surgery.» And that was just the start of it.
But it was all worth it, she said.
«It saved my life,» Claire, 33, said. (She asked that Business Insider withhold her last name to protect her privacy.) «My worst day now is better than the best day I had when I presented as male. I am able to exist without fear, without compromise.»
an estimated 1.4 million people in the US, Claire is transgender. She was designated male at birth, but she is a woman. And she's known that, on some level, since elementary school, she said.
It didn't take long for Claire to realize that being transgender comes at a cost. By the time she came out in 2013, she was already struggling with what's commonly called gender dysphoria , a form of emotional distress that results from identifying as a different gender than the one designated at birth.
But for Claire and many other transgender people, the costs aren't just emotional: Many are also financial.
The cost of medical treatments can add up to more than $100,000, and they're often not covered by health insurance.
Plus, transgender people face discrimination in the workplace, which translates to unemployment rates that are as much as three times as high than they are for the general public.
Medical procedures are often essential, but they come at a cost
Claire, a transgender woman living in New York, estimates that she's spent thousands of dollars on her medical care. Brett Jordan/Business Insider
For many years, doctors tried to alleviate gender dysphoria with talk therapy.
But in the absence of surgeries and other medical interventions, that approach was an «abysmal failure,» Joshua Safer, the executive director of the Center for Transgender Medicine and Surgery at New York's Mount Sinai Hospital, said.
«We have suicide attempt rates of 40% among transgender people where there are no [medical] interventions offered, and so we know that's a failed strategy,» Safer said.
Now, most medical professionals offer trans patients hormones and surgeries to change their bodies to match their gender identities. Surgeons can construct a penis (phalloplasty) or vagina (vaginoplasty), augment or remove the breasts, and feminize or masculinize the face with plastic surgery.
The procedures are long, complicated, and often painful. Vaginoplasty, for example, is a six-hour surgery with a recovery time of up to a year and a half, while phalloplasty has a similar recovery time and can take as long as 12 hours in the operating room.
But they're known to work, and they can save lives by helping trans people feel comfortable and safe in their own skin.
«It is a life or death thing,» Claire said. «It feels you can't breathe when you're not allowed to just be yourself and be comfortable in your own skin.»
Nonetheless, many transgender people don't get surgery, by choice or because they can't afford the cost.
Trans-related surgeries can cost tens of thousands of dollars, yet insurance companies don't always cover them
Bilateral mastectomies for transgender men can cost as much as $10,900, according to the Philadelphia Center for Transgender Surgery.
Brett Jordan/Business Insider
While cost estimates vary widely, the Philadelphia Center for Transgender Surgery estimates that «bottom surgery» costs about $25,600 for male-to-female patients and about $24,900 for female-to-male.
The center provides estimates for other common trans-related surgeries, such as breast augmentation ($9,000), bilateral mastectomy (up to $10,900), facial feminization (up to $70,100), and facial masculinization (up to $53,700).
These are out-of-pocket expenses for an estimated 14% of transgender people who are uninsured or whose insurance won't cover the procedures. And they don't include the price of ongoing therapy and other medical care, such as visits to a specialist for hormone therapy.
Under the 2014 Affordable Care Act and a handful of other laws with antidiscrimination provisions, insurers are required to cover medically necessary care for trans people. And an increasing number of them do. About 83% of companies surveyed by the Human Rights Campaign, for example, offer healthcare benefits that cover transgender care, up from 9% in 2010.
Public healthcare providers are also increasingly covering transgender care.
Medicare, the US government health program for the elderly and people with disabilities, began covering gender-affirming surgeries about five years ago.
Earlier this year, Illinois joined 17 other states and the District of Columbia when it announced that its Medicaid program for people with low incomes would cover gender-affirming surgery.
On May 29, 2014, Denee Mallon, a transgender woman who was denied coverage for gender-affirming surgery under Medicare, attended the Trans March to Morningside Park in Albuquerque, New Mexico. The next day a federal health board ruled to dismantle a Medicare ban on the procedure. Craig Fritz/AP
Gaps in insurance coverage persist
«Access to competent inclusive healthcare for transgender people has increased,» Naomi Goldberg, a policy director at the LGBT think tank Movement Advancement Project, or MAP, said.
She credited several recent changes in the US, including «increased understanding about what it means to be transgender,» in addition to «improved medical care and standards, and improved education for healthcare providers.»
But gaps in coverage remain. In Arizona, for example, the American Civil Liberties Union is suing the University of Arizona for listing explicit exclusions for «gender-reassignment surgery» in their healthcare plans.
According to MAP, several states, including Wyoming and Alaska, have language in their laws that bans coverage of certain treatments for transgender patients in state Medicaid programs, such as what Alaska calls «transsexual surgical procedures.»
In Alaska, the exclusion is the subject of a court fight and the state declined to comment. Wyoming's Medicaid director didn't respond to a request for comment.
«The landscape varies across the states with some states proactively updating their policies, others doing nothing, and others continuing to defend preexisting bans [on trans coverage],» Logan Casey, a policy researcher at MAP, said. «So even though the ACA should mean medically necessary care is covered, the reality on the ground is quite different from state to state.»
Defining what's 'medically necessary'
Casey and other experts familiar with transgender care point out another problem: The definition of «medically necessary» in healthcare plans typically excludes a number of procedures, including breast augmentation, body contouring, and facial feminization. Insurers often refer to these surgeries as cosmetic and won't pay for them.
Insurers have always categorized these procedures as cosmetic when the patient is cisgender, meaning they identify with the gender they were designated at birth. But according to Safer, they can be medically necessary for trans people, by helping alleviate dysphoria. They can also make trans people less ly to be targets of violence, he said.
«If a significant point for [a trans woman] is to be able to walk down the street and be treated appropriately according to her gender identity, then having a feminine face is going to be enormous, both for how she's treated and, frankly, for safety,» Safer said.
In a 2015 survey, 55% of more than 27,000 transgender people reported being denied coverage for at least one gender-affirming surgery.
Earlier this year, Claire's insurance provider refused to cover a scheduled breast augmentation, which can cost about $9,000. Brett Jordan/Business Insider
Claire gets her health insurance from one of the largest insurance providers in the US. (She asked that Business Insider not identify the company, saying it may weaken her case for an appeal in the future.) Her insurer covered a vaginoplasty in 2018, but the company refused to cover a breast augmentation she had scheduled for earlier this year, she said, even after appealing the denial.
«They came down hard and said no,» she said. «Now it means that if I want to get that procedure, which I need, so I can feel comfortable with myself, just to be able to stand in the mirror and look at myself, I'm going to have to pay pocket.»
To pay for procedures that insurers consider cosmetic, transgender people often seek help from friends or turn to crowdfunding platforms Indigogo and GoFundMe. A quick search for «transgender surgery» on GoFundMe, for example, yields more than 3,000 results. The site offers a guide on how to fund «gender-confirmation surgery.»
'Cis guys don't have to pay for their penises'
Emmett J. Lundberg, an actor in New York City, said he raised about $5,000 on the fundraising site Indiegogo in 2013 to help cover the cost of top surgery.
«I was lucky to have a lot of people in my life that were able to contribute to that, but I still had a lot of extra costs,» he said. Those don't stop at medical procedures. There are a lot of other expenses most people never have to think about, such as chest binders and prosthetic genitals for transgender men.
«I mean cis guys don't have to pay for their penises,» Lex, a trans man, said.
Lex, a transgender man living in New York, has purchased binders to conceal his chest. Ben Nigh/Business Insider
There can also be fertility treatments, new clothes for after surgery, and hair removal — lots of hair removal, Claire said.
«The most expensive thing for a trans woman is hair removal,» Claire said. «You have to go every week,» she said. «It's about $75 to $100 every session. That's just for your face. And you could be doing this for anywhere from three to seven years.»
It comes to the point where you can drown in debt from these expenses, Claire said.
«It just adds up,» she said. «But you do it because it's what you need to do.»
The high cost of being transgender
- It can cost more than $100,000 for a transgender person to transition
- Some who can't afford a medical transition fear negative reactions and violence from others
(CNN)Nicholas Ballou binds his chest each day before leaving his home. It's so tight he often finds it hard to breathe and has gotten lightheaded. Throughout the day, he might touch his chest or adjust the wrap — a nervous habit. Nothing can be place.
Ballou, a transgender male, cannot afford top surgery, which would get rid of his breasts and give him a more male-looking chest. At 23, he has wanted to have this surgery for 10 years, but it's expensive and it's unly he'll be able to cover the costs anytime soon.
Caitlyn Jenner's highly publicized and often celebrated transition from male to female is not typical of what most transgender people experience. Jenner said so recently in her acceptance speech for ESPN's Arthur Ashe Courage Award at the annual ESPY Awards ceremony.
«If you want to call me names, make jokes, doubt my intentions, go ahead. Because the reality is, I can take it,» Jenner said. «But for the thousands of kids out there coming to terms with being true to who they are, they shouldn't have to take it.»
As part of her transition, Jenner reports having completed a facial feminization surgery, hormone therapy and breast augmentation.
Many transgender people transition without surgery. Some say they don't want surgery, or are interested in only some of the medical options available.
But many cite the cost of the procedures — potentially more than $100,000 pocket — and the lack of insurance coverage as a barrier to their transition.
Still, they worry about how going without might affect their mental health and safety.
The surgery: What does it cost?
The cost of a transgender person's transition can vary widely, and pricing information is often not available.
Eugene Schrang, a Wisconsin surgeon who specialized in gender reassignment surgeries before retiring in 2007, said most patients paid pocket for their surgeries, and it was rare for insurance to cover the procedures.
Factors that affect the cost include the number of surgeries people want, where the surgeries take place and what type of insurance they use.
They also might incur additional costs for travel, hospital stays and psychological evaluations.
In Pennsylvania, the Philadelphia Center for Transgender Surgery posts cost estimates for different procedures. Its price list mentions estimates of $140,450 to transition from male to female, and $124,400 to transition from female to male.
This list, un many others, includes potential costs for things such as anesthesia, hospital stay and each of the potential surgeries that someone transitioning from one gender to the other may want or require.
These numbers are one surgery center though, and will change depending on factors such as insurance, the hospital that is attended or if someone is using a different surgery center altogether.
Jo Avelyn Grey came out as transgender to her family at 11 years old and began to transition medically four years ago, in her early 20s.
Some of Grey's medical expenses are covered by her insurance, Kaiser Permanente, including her hormone therapy, a portion of her gender reassignment surgery and preparatory genital electrolysis that has to be done before the surgery.
The insurance does not cover facial electrolysis (beard removal), laser body hair reduction, breast augmentation or facial feminization surgery, all of which Grey considers vital to her survival as a transgender woman.
«No one sees me as physically female, just obviously transgender. This makes me an outcast and puts me at an extremely elevated risk for discrimination and harassment,» Grey said. «Just covering hormones and gender reassignment surgery is a half measure that still leaves us exposed to great risks and complications in our everyday lives.»
Deborah Espinal, executive director of health plan policy for Kaiser Permanente, said in a statement, «Kaiser Permanente is committed to providing culturally competent care to all of our members and patients.
We continue to provide a spectrum of services, in compliance with state mandates, for transgender individuals that includes hormone replacement therapy and behavioral health services throughout all the states that we serve.
«In some states, mandated services include services such as gender reassignment surgery, and mastectomy with chest reconstruction.
Our approach is to evaluate service coverage both in terms of what is required by each state and what these patients need to have available to them in order to properly transition.
As with all health care decisions, we encourage our members who are interested in transgender medical services to discuss their health care needs with their Kaiser Permanente physician.»
In addition to the surgeries that her insurance does not cover, Grey pays a $30 copay for genital electrolysis sessions, which she must attend two to three times each week for about a year before her gender reassignment surgery. She estimates that by the end of her transition, she will have paid $70,000 to $80,000 pocket.
Insurance and surgery
More insurance plans are ly to cover transitional procedures for transgender people than in the past.
In a 2013 survey by Jody Herman, manager of transgender research at the Williams Institute, employers characterized the costs of covering transition-related coverage «negligible» and «minimal» because so few people used those services. The survey included 34 U.S. employers who cover transition-related health care. There are between 100 and 500 genital surgeries every year in the United States as part of gender transition, according to the Encyclopedia of Surgery.
«Overall, we find that transition-related health care benefits have zero or very low costs, have low utilization by employees, and yet can provide benefits for employers and employees a,» Herman writes.
In 2014, the Affordable Care Act, commonly referred to as Obamacare, stated that health insurance providers could no longer discriminate gender or health history, thoughsome insurance agencies are finding ways to get around this policy change.
Ballou said that while this development is a helpful step, it hasn't allowed him to obtain the coverage he needs to get top surgery.
He has bound his chest for 10 years and said it's intensely painful to ensure that no one knows he was born a woman.
He does not have insurance because he said that the insurance agencies that provide Obamacare in Nevada still mark the surgery as cosmetic. He is currently uninsured while he searches for a company that can adequately fit his needs.
Ballou said he realized he was transgender when he was 3. He recalls running around his backyard in his underwear, screaming at his mother that he would not put on a dress because he was a boy. He first realized there was a word for who he was at 13, and he began to transition with hormone treatments when he was 16.
Ballou is still struggling to become the person he wants to be. In California, where he grew up, state law says health insurance companies must cover transgender health care. He was on an eight-month waiting list to obtain the surgery finally when he switched jobs and moved to Nevada.
He has had no luck in finding a health insurance that will cover the surgery; all the companies he has called label it as cosmetic.
The costs of not transitioning
Even as many insurance companies label transition-related surgeries as cosmetic, transgender rights activists argue that the surgeries are necessary and could decrease mental health issues and violence toward transgender people.
Kristen Lovell, a transgender woman in New York, said that the culture has changed from 15 years ago when she was going through her transition. Still, through her work at Sylvia's Place, an emergency shelter in New York, she sees that transgender people continue to face violence and that people who are unable to transition are more ly to feel depressed or attempt suicide.
The National LGBTQ Task Force says that one in four transgender people have experienced violence. The American Psychological Association says that the lack of acceptance for a transgender person createsan inner sense of not belonging as well as discrimination and harassment by society.
«Passability is definitely a privilege,» Lovell said. «As you're transitioning, you're prone to have increased lash outs from people because your appearance isn't appealing to them. People always want to fight what they don't understand. It puts people who are starting to transition in danger.»
Passing defines one person living in his or her chosen gender without anyone knowing he or she ever lived in a different one,according to the National LGBT Cancer Project. In broad terms, passing can mean different things to different transgender people, but it usually refers to no one being able to tell that an individual is transgender.
Ballou said he lives in constant fear, and he'll continue to bind his chest each day and search for a way to have his medical procedure. He said he may need to move back to California to have it done.
«I haven't stepped my house in 10 years without serious binding,» he said. «It's constantly on my mind; I'm never not thinking about it. It's really hard. It's just a consistent fear.»
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Medicare for transgender-related health care
- 1.4 million adults in the United States identify as transgender
- Hormone therapy typically costs $100 per month
- Gender affirmation surgery usually costs between $7,000 and $50,000
- There are approximately 10,000 transgender Medicare beneficiaries
- Medicare covers medically necessary transgender surgery on a case-by-case basis
- Those insured through Medicare are more ly to get transition-related surgery than those with private insurance
Over 1.4 million adults in the United States identify as transgender. Gender-affirming surgeries and hormone therapy can be an essential part of a trans person’s transition, but those procedures can be costly, and many private insurance plans don’t cover them.
For the relatively small number that qualifies for Medicare coverage — just 0.7% of transgender people are Medicare beneficiaries — Medicare can provide significant relief. Medicare ensures that medically necessary care is covered, including some gender confirmation procedures.
Many trans people opt to undergo forms of medical transition so their appearance better aligns with their gender identity. Some — but not all — decide to get gender-affirmation surgery, including procedures breast removal or augmentation and genital reconstruction.
For those who utilize hormones, the cost is typically $100 per month, and support during this time through therapy is approximately $100 per session.
Trans people who want gender-affirmation surgery need a substantial amount of money to cover the expense. Depending on the procedures they need, gender-affirmation surgery can cost between $7,000 and $50,000, but some procedures — such as phalloplasties — cost even more.
For decades, Medicare specifically excluded transgender surgery and related procedures. Anyone attempting to get Medicare transgender coverage was denied because the procedures were deemed “experimental.”
In 2014, the Centers for Medicare & Medicaid Services issued a new determination that removed the existing exclusion for transgender surgery. Now, Medicare will determine coverage of transgender-related procedures on a case-by-case basis.
In addition, Medicare must cover routine preventative care if it’s clinically necessary, regardless of the gender marker on your Social Security records. If there is a potential for gender mismatches between your records and gender identity, the physician or hospital should use billing code (condition code 45) to help process your claims.
To qualify for Medicare coverage for treatment, you must meet the following criteria:
- You have been diagnosed with gender dysphoria, previously known as gender identity disorder
- You have completed at least 12 months of continuous hormone therapy
- You have lived for at least 12 months as the gender role you’re transitioning to
- You are free of serious medical or mental health issues or are receiving sufficient medical care to control those issues
- You need two recommendations from mental health providers
If you meet those requirements, your doctors can submit your case for Medicare coverage, and you’ll ly get assistance with your transition costs as long as your doctors participate in Medicare. However, you’ll still be responsible for Medicare deductible and coinsurance.
If you have a Medicare Advantage plan, your health-care provider will ly have to submit your case to the insurance company for prior authorization before you can get coverage for procedures or hormone therapy.
However, not all health-care providers accept Medicare, so make sure you double-check with your doctor to find out if your procedure is covered.
RELATED: Find out if there are Medicare Advantage plans in your area.
Does Medicare cover hormone therapy?
If you are prescribed hormone therapy, Medicare Part B will pay for your lab work and doctor visits to monitor your response to the hormones. However, Original Medicare doesn’t cover the cost of the hormones. You’ll have to pay for them pocket, or you can enroll in a prescription drug plan, also known as Medicare Part D, at an additional cost to get coverage for hormone therapy.
Does Medicare cover transgender surgery?
Gender-affirming surgery, also known as gender confirmation surgery, is a term that refers to a series of procedures a transgender person may undergo to achieve the physical appearance that fits their identity.
Medicare covers medically necessary transgender treatments, including gender-affirmation surgery, on a case-by-case basis. If approved, Medicare Part B — medical insurance — will pay for your doctor visits and approved surgery. Medicare Part A — hospital insurance — covers inpatient care.
As a transgender person, gender-affirming surgeries can have a significant effect on your well-being. However, not all procedures are covered by Medicare. To qualify for Medicare coverage, procedures must be classified by the insurance company as “medically necessary” rather than “cosmetic.”
Coverage for transgender procedures is typically limited to those that change primary sex characteristics, including:
- For people assigned female at birth and transitioning: Removal of breasts, ovaries, and uterus, and genital reconstruction
- For people assigned male at birth and transitioning: Removal of the penis, testicles, and prostate gland and genital reconstruction
While trans individuals often undergo other procedures to make their appearance match their gender identity, such as facial contouring or hair transplants, Medicare designates these procedures as cosmetic and does not cover them.
RELATED: Speak with a licensed Medicare insurance agent by calling: 844-259-6504.
If your request for health-care services or procedures is denied, you have the option of appealing that insurance company’s decision and requesting a redetermination.
If you have Original Medicare, complete the Redetermination Request Form and send it to the company that handles your Medicare benefits. In the request, include your name, address, and Medicare number.
Circle the items you disagree with and include a written explanation of why you think the items should be covered. Include any supporting documentation, such as medical records or statements from your doctor.
If you are on a Medicare Advantage plan, you typically have 60 days after receiving a denial to file an appeal. While some plans allow you to appeal over the phone, others require you to appeal in writing, so make sure you check your insurance company’s policies.
If you’d to consult a licensed Medicare professional before selecting the Medicare coverage that’s right for you, call 844-259-6504 and ask about Medicare for transgender-related health care.
Transgender Health Benefits
Most people are covered by some form of health insurance, whether it beemployer provided, Medicare/Medicaid, or purchased by the individual. These health plans normally cover necessary medical care. Typicalhealth plans have an exclusion list declaring certain types of medicalcare to be uncovered. Some medical plans include transsexualneeds on their exclusion list.
According to theWorld Professional Organization for Transgender Health,medically necessary procedures transsexuals usually must undergo include
- Psychological counselling, for the initial diagnosis, for guidance throughthe transition, and to obtain the letter required for surgery
- Hormone Replacement Therapy (HRT) to adjust their body to their new genderrole
- Doctor's office visits in support of HRT.This includes lab work and other monitoring of the HRT.
- Permanent facial hair removal for transsexual women.This will usually include laser treatments and/or electrolysison the face and neck, and possibly on the body.
- Breast augmentation (or prosthesis) for trans women.
- Bilateral mastectomy and chest reconstruction for transsexual men..
- A hysterectomy may also be medically indicated for trans men.
- In many cases,genital reconstruction (also called sex reassignment surgery)is also indicated for both trans men and women.
- Skin flap hair removal.
- Penile and testicular prostheses, as necessary for trans men.
- Certain facial plasticreconstruction as appropriate to the patient.
Nongenital surgical procedures are routinely performed…notably, subcutaneous mastectomy in female-to-male transsexuals, and facialfeminization surgery, and/or breast augmentation in male-to-femaletranssexuals. These surgical interventions are often of greater practicalsignificance in the patient's daily life than reconstruction of thegenitals.[Monstrey S, De Cuypere G, Ettner R,.(2007) . Surgery: General Principles. In Ettner R et al (eds) Principles of Transgender Medicine and Surgery. New York:Haworth Press:2007.p.90.] These procedures are not optional, but may be required to save a life. They are also required by mosts states before personal documentation,such as the drivers license and birth certificate, can be updatedwith a new gender marker, permitting the person to live a normal life.
Yet some insurance policies continue to exclude coverage of these needs.
Is refusal to cover transgender health benefits discriminatory?This can best be answered by checking to see if the same medicalprocedures would be covered for non-transsexuals by the same plan.
Is Hormone Replacement Therapy covered for post-menopausal women?Would Vaginoplasty or Phalloplasty be covered after an accidentalinjury or cancer?Are Mastectomies or Hysterectomies covered in case of cancer?Would gynocomastica, caused by a hormone imbalance, be covered?These are some of the same treatments andprocedures needed by transsexuals.A fair health plan covers the same procedure for all employees,whether or not it is related to transsexualism.
The average cost for a male-to-female surgery is about $17,000.Adding in a cost of about $1000 for therapy, $1500 for hormones,and $500 for doctors visits and lab tests, the cost to transitionaverages about $20,000 over a two year transition period.(After completion of surgery, ongoing costs drop dramaticallyto cover only a small maintenence level of hormones.)
If these procedures are not covered by insurance, the transsexualmust pay for them personally. Most surgeons require payment in advance.People have to save money for years to complete their transition.Those in lower paying jobs often can never afford the surgery.The impact on an individual can be overpowering.
How much would it cost your company to cover the basic medicalneeds of a transsexual?Transsexualism is very rare.
According to the DSM-IV, it affects an estimated 1 in 30,000 people,The latest research estimates that the total annual cost per insuredis $.05 to cover surgery, or $.17 to cover surgery, hormones, and therapy.
With medical insurance costing upwards of $4,000 per year,the to cover THBs would be about .004%.
TAW has prepared aResearch Report.that will help employersestimate the cost of THBs for their work force.
Is treatment considered «Medically Necessary?»
When a company decides to cover medical needs for its transsexual employees,it's not uncommon for the insurance company to still refuse coverage.Typical plans are worded so that the insurance company makes the determination,even though the plan is employer designed.
It is often necessary to appeal to the company to approve coveragethat the employer intended to cover.
In the past, it was commonplace for an insurer to claim that transsexualneeds were experimental or cosmetic.
The original surgery of Christine Jorgenson in 1952 was experimental.Today, the procedures are routine, and thousands undergo them each year.
Those undergoing the surgery must comply with theHarry Benjamin Standards of Carewhich strictly outlines the diagnosis and procedure that mustbe followed for a true, medically necessary transition.
Recently, insurance companies have begun to claim that transsexualprocedures are not medically necessary.
When encountering such terms as experimentaland medically necessary it is helpful to refer tothe definitions of these terms as often used in medical practice.One useful glossary is on the Lucent benefits web site athttp://184.108.40.206/mgt/library/mep/content.
asp.The set of definitions can be found athttp://220.127.116.11/mgt/library/mep/pdf/terms.pdf(If the web address above has changed, the content can be foundhere.)
When referring to these terms, language such as «standard, tested and accepted effective practice by the medical community at large»and «recognized standards of the health care speciality involved» will be found.It is useful to follow the logic of this standard.
A transsexual is usually diagnosed with «Gender Identity Disorder»,302.85 in the DSM IV.
Following the accepted psychological, psychiatric, and medicaltreatment for this diagnosis, one finds that the appropriatestandard of diagnosis and treatment is theHarry Benjamin Standards of Care.
These standards outline the appropriate and effective treatmentfor Gender Identity Disorder, including counselling, medical,and surgical.Applying the definitions, most practitioners will conclude thatthe treatments are indeed medically necessary by the recognizedstandards for medical necessity.
TheHarry Benjamin Standards address this issue directly:Sex Reassignment is Effective and Medically Indicated in Severe GID. Inpersons diagnosed with transsexualism or profound GID, sex reassignmentsurgery, along with hormone therapy and real-life experience, is atreatment that has proven to be effective.
Such a therapeutic regimen, whenprescribed or recommended by qualified practitioners, is medicallyindicated and medically necessary. Sex reassignment is not «experimental,»»investigational,» «elective,» «cosmetic,» or optional in any meaningfulsense. It constitutes very effective and appropriate treatment fortranssexualism or profound GID.
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