Jan 29 (Reuters) - A U.S. government panel has ruled that a privately run Medicare plan must cover sex reassignment surgery for a Texas transgender woman, a decision her attorney said was the first of its kind.
Charlene Lauderdale, a U.S. Air Force veteran, first sought surgery through her UnitedHealthcare/AARP Medicare Complete insurance plan in November 2014. The federally funded plan, operated by a unit of UnitedHealth Group Inc, denied the request.
An administrative law judge with the U.S. Department of Health and Human Services ruled last April that the plan must cover the surgery, and the agency’s Medicare Appeals Council upheld that decision this month.
Lauderdale’s lawyer, Ezra Young, said he received the council’s decision on Thursday.
“I am so relieved that I can now get the medical care that I have needed for so long,” Lauderdale, 55, said in a press release. “I hope that my decision will help other transgender Americans who have also been denied health care.”
Until May 2014, Medicare excluded all sex reassignment surgery. Since that ban was lifted, coverage decisions for surgery and other transgender health services under Medicare have been made on a case-by-case basis.
According to Young, many transgender patients have been unable to get coverage for sex reassignment surgery because insurers or contractors hired by Medicare to make such determinations have decided the procedure is cosmetic, or not medically necessary, among other reasons.
Young said the decision in Lauderdale’s case was the first time HHS ordered a Medicare Advantage plan to cover sex reassignment surgery. Though the decision is not legally binding on other cases, Young said he believed it would set an important “guidepost.”
In reaching its decision, the appeals council cited standards of care developed by the World Professional Association of Transgender Health, which first released such standards in 1979.
It rejected UnitedHealthcare’s argument that the surgery was not right for Lauderdale because she had suffered psychiatric problems, which led to four hospitalizations in 2014.
The council noted that untreated gender dysphoria, a feeling that a person’s body does not match his or her gender, can itself cause psychological distress.
If UnitedHealthcare wants to challenge the decision, it must bring a lawsuit in federal court, according to Young.
A spokeswoman for UnitedHealthcare could not immediately be reached for comment.
HHS is currently considering a proposed regulation that would forbid private insurers from discriminating against transgender patients, as well. (Reporting By Brendan Pierson in New York, Editing by Anthony Lin and David Gregorio)