Allison Escolastico, a 30-year-old transgender woman, has wanted a breast augmentation for a decade. By 2019, she finally believed her insurance company Aetna would pay for it, but found the procedure was considered cosmetically rather than medically necessary and refused to cover it.
“I knew from my case that it wasn’t cosmetic,” said Ms. Escolastico, who turned to a lawyer after losing her appeal last year. “I knew I had to fight for it,” she said.
Ms. Escolastico’s operation is now scheduled for February. Working with the Transgender Legal Defense and Education Fund, a nonprofit advocating for transgender rights, and Cohen Milstein Sellers and Toll, a large law firm representing plaintiffs, she and a small group of trans women convinced Aetna to take the case to cover if you can prove it must be medically necessary.
To qualify, women would need to demonstrate that they have persistent gender dysphoria, undergo feminizing hormone therapy for a year, and receive a referral from a mental health professional.
Aetna’s shift represents an important development in how health insurers view the medical needs of transgender people. While some insurers offer a wide range of surgeries for trans women when deemed medically necessary, others include breast augmentation and other treatments than cosmetic treatments only.
“This has the potential to be a transformative moment,” said Kalpana Kotagal, partner at Cohen Milstein.
Insurers have usually covered genital reassignment surgery as medically necessary. However, transgender women and others say breast augmentation is also a necessary treatment for those diagnosed with gender dysphoria. “From a medical standpoint, there is no question,” said Noah E. Lewis, the director of the fund’s Trans Health project.
In addition, it is illegal for a health insurer to refuse coverage based on a person’s gender identity. “It’s a really simple matter of discrimination,” he said.
Aetna, owned by CVS Health, has been actively investigating the need for breast augmentation surgery for trans women, said Dr. Jordan Pritzker, senior director for clinical solutions at the insurer. He said he spoke to numerous doctors who will perform the surgery.
“Our decision to update our clinical guidelines bulletin is in line with many changes we have made over the years to meet the requirements of the L.G.B.T.Q. Community, “said Dr. Pritzker in a statement.
Aetna said it would also reimburse some trans women who were denied coverage but who had surgery. The company said it had actively reached out to people who had requested permission for their operations and who were refused.
Cora Brna was denied coverage for breast augmentation surgery two years ago when she tried to schedule it at the same time as the genital repositioning that was covered by Aetna. “I was devastated,” she said.
“I felt like a group of people were deciding whether or not I was a woman,” said Ms. Brna, 32, who works as a health worker in Pittsburgh and was one of the women who applied for Aetna. She performed the genital surgery but had the procedure of enlarging her breasts only after she was covered by another health plan.
Aetna’s new policy also comes at a time when the federal government is re-examining whether it is discriminatory to deny certain types of care to transgender people. Under the Affordable Care Act, insurers cannot discriminate against people based on their gender identity, and most insurance companies provide coverage for people who need sex reassignment surgery. However, the law never mandated a specific benefit or specified exactly what services insurers would cover, said Katie Keith, who teaches law at Georgetown University and is closely following that area of law.
“It’s almost like a parity problem,” she said.
While the Trump administration tried to remove protection for transgender people with a rule last June“The problem is still being resolved in court,” said Ms. Keith, who also pointed out the latest Supreme Court decision These gay and transgender workers are protected from discrimination in the workplace under the Civil Rights Act.
The new Biden administration has already issued an executive order It will enforce civil rights laws that protect people from discrimination based on gender identity.
Large insurance companies have uneven coverage. Health Care Service Corp., which offers Blue Cross plans in five states, pays for breast augmentation and other services for trans women when deemed medically necessary. The insurer said it developed these guidelines according to the guidelines of the World Professional Association for Transgender Health, a nonprofit organization.
However, other major insurers, including Anthem and UnitedHealthcare, continue to view the surgery as cosmetic as it generally doesn’t cover the procedures for women without a diagnosis of gender dysphoria. They say they don’t discriminate against trans women.
Anthem says his “medical policies are applied fairly to all members, regardless of gender or gender identity.”
And UnitedHealthcare said in a statement that “coverage for the treatment of gender dysphoria is comprehensive and that current coverage may include doctor visits, mental health services, prescription drugs and surgery to treat gender dysphoria, depending on members’ benefit plans”. It added that it “uses evidence-based medicine to make coverage policy decisions,” which are updated regularly.
However, the lawyers for the women involved in the Aetna arrangement say they are scrutinizing other insurers’ policies to see if they can make the same claim that their refusal to offer coverage is discriminatory. “This needs to be changed across the industry,” said Ms. Kotagal of Cohen Milstein.