Justice Affirmed: Medicare reimburses client for gender-affirming surgery

Our client, “Sara,” a 52-year-old trans woman from Central Pennsylvania living with HIV, knew she needed surgery to affirm her gender identity. Her medical team in Philadelphia knew she needed it.But would Medicare cover this necessary service?Knowing from experience that the struggle for Medicare payment would be long and complicated, the surgical team suggested that Sara pay for it and then seek reimbursement from Medicare. Sara turned to her family for financial assistance. They knew she had suffered all her life from gender dysphoria, and they offered to pay for the surgery. After her surgery was completed, Sara felt secure enough to request that Medicare reimburse her. But Medicare denied her request, claiming the surgery was cosmetic and therefore not a covered service. The AIDS Law Project of Pennsylvania had helped Sara with many issues over the years. So she turned to us for help when Medicare denied her claim. We filed an appeal arguing that her history and medical documentation established that the gender-affirming surgery was reasonable and necessary. Medicare denied the appeal, claiming that Sara’s documentation did not detail her gender dysphoria diagnosis. We appealed again and requested a hearing before an Administrative Law Judge. This month, the judge issued a decision without the need for a hearing. The judge specifically found that the “gender reassignment surgery services were not for cosmetic purposes, but a part of a comprehensive, medically necessary treatment plan for gender dysphoria.”Sara felt vindicated that Medicare finally recognized that her surgery was necessary and that it was a covered service.