Medicare abandoned its previous (negative) national coverage determination for gender reassignment surgery in 2014. Now it has begun the review process on a request for a new one -- which may affirm Medicare coverage of the procedure across the country.
According to a tracking sheet posted Dec. 3, CMS acknowledged receipt of a letter from Nehael Jae Shields requesting “under the rules a formal and complete National Coverage Determination” on “Surgical Remedies for Gender Identity Disorder." Shields said she made a similar request earlier, which she claimed CMS had received but later removed from their site.
The sheet indicates CMS is now conducting "National Coverage Analysis (NCA)" for Gender Dysphoria and Gender Reassignment Surgery.
HHS had previously issued an NCD that directed Medicare contractors not to accept claims on such treatments. But on May 30, 2014, its Departmental Appeals Board (DAB) reversed that ruling.
"The Board has determined that the National Coverage Determination (NCD) denying Medicare coverage of all transsexual surgery as a treatment for transsexualism is not valid under the 'reasonableness standard' the Board applies," the decision said. "...Since the NCD is no longer valid, its provisions are no longer a valid basis for denying claims for Medicare coverage of transsexual surgery, and local coverage determinations (LCDs) used to adjudicate such claims may not rely on the provisions of the NCD."
At least one Medicare contractor, Palmetto, has an LCD for Gender Dysphoria and Gender Reassignment Services.
On the tracking sheet CMS acknowledges receipt of Shields' complaint and says it is "soliciting public comment relevant to the request. We are particularly interested in comments that include scientific evidence and that address the breadth of the request."
CMS is accepting comments until January 3, 2016. Their decision memo is expected to appear on June 3.