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CMS: No NCD for gender reassignment surgery, coverage choice up to MACs

CMS finalized its decision not to have a national policy for Medicare coverage of gender reassignment surgery; instead, individual Medicare administrative contractors (MACs) will decide whether to cover the procedure.

The agency issued its "Decision Memo for Gender Dysphoria and Gender Reassignment Surgery" decision memo Aug. 30. "In the absence of a NCD [national coverage determination], coverage determinations for gender reassignment surgery ... will continue to be made by the local MACs on a case-by-case basis," it says in part. MACs will make their decisions "based on whether gender reassignment surgery is reasonable and necessary for the individual beneficiary after considering the individual’s specific circumstances." Medicare Advantage plans will make similar decisions for its beneficiaries.

CMS also specifies that it did not "analyze the clinical evidence" nor make a coverage determination on "counseling, hormone therapy treatments or any other potential treatment for gender dysphoria." The agency "encourages robust clinical studies" of appropriate gender dysphoria treatments. 

CMS policy had been not to cover reassignment surgery under any circumstances, but that was reversed by a decision of HHS Appeals Board in response to a beneficiary complaint in 2014. On Dec. 3, 2015, CMS announced it would consider a new policy; in June, they issued a proposed decision not to create an NCD, essentially confirmed in the final.

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