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
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
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."
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.
[to top of second column]
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
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
HHS is currently considering a proposed regulation that would forbid
private insurers from discriminating against transgender patients,
(Reporting By Brendan Pierson in New York, Editing by Anthony Lin
and David Gregorio)
[© 2016 Thomson Reuters. All rights
Copyright 2016 Reuters. All rights reserved. This material may not be published,
broadcast, rewritten or redistributed.