No Universal Coverage for Gender Reassignment Surgery: CMS

Megan Brooks

June 20, 2016

Currently there is not enough evidence to support universal coverage of gender reassignment surgery for Medicare beneficiaries with gender dysphoria, the Centers for Medicare & Medicaid Services (CMS) has indicated. The proposed decision, which is not final, is open for public comment until July 2.

The CMS proposes continuing to have local Medicare administrative contractors make coverage decisions regarding gender reassignment surgery on an individual claim basis.

The CMS "proposes to continue this practice and not issue a National Coverage Determination (NCD) at this time on gender reassignment surgery for Medicare beneficiaries with gender dysphoria," the organization notes in a statement.

"Our review of the clinical evidence for gender reassignment surgery 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," the agency adds.

It called for "robust" clinical studies to "fill the evidence gaps."

"Based on the gaps identified in the clinical evidence, these studies should focus on which patients are most likely to achieve improved health outcomes with gender reassignment surgery, which types of surgery are most appropriate, and what types of physician criteria and care setting(s) are needed to ensure that patients achieve improved health outcomes," the CMS says.

Not Yet Final

In an interview with Medscape Medical News, Jack Drescher, MD, member of the American Psychiatric Association's (APA's) DSM-5 Sexual and Gender Identity Disorders Work Group, said he does not find the decision surprising and noted that there is "not a huge" Medicare population for this.

Dr Drescher said, "It's hard to speculate, but anytime you have more hoops for patients to jump through in order to access services, you only increase patient anxiety and stress. That would be true of any medical condition.

"I don't think there is anything wrong, per se, of having an individualized approach, but it has to be a very streamlined approach so it doesn't turn out to be an obstacle to access to care but actually something that would facilitate access to care," said Dr Drescher, who is clinical professor of psychiatry and behavioral sciences, New York Medical College, in Valhalla.

The proposed decision is open for public comment until July 2. The CMS has indicated that it is interested in comments on the evidence that has already been cited, comments containing new evidence that has not been considered, and comments on whether a study on gender reassignment surgery for Medicare beneficiaries could be developed that would support coverage with evidence development.

A final decision is expected in the fall.

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