Medicare denies national coverage for gender reassignment surgery: No evidence of therapeutic outcome

August 31, 2016

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On June 2, 2016 the Centers for Medicare & Medicaid Services (CMS) denied national coverage for gender reassignment surgery after the agency conducted a  year long review which determined that there is no medical evidence of a therapeutic outcome for patients who have undergone these procedures.

 

Excerpts from their report:

 

On December 3, 2015, CMS accepted a formal complete request from a beneficiary to initiate a national coverage analysis (NCA) for gender reassignment surgery.

CMS opened this National Coverage Analysis (NCA) to thoroughly review the evidence to determine whether or not gender reassignment surgery may be covered nationally under the Medicare program.

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In general, when making national coverage determinations, CMS evaluates relevant clinical evidence to determine whether or not the evidence is of sufficient quality to support a finding that an item or service is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. (§ 1862 (a)(1)(A)). The evidence may consist of external technology assessments, internal review of published and unpublished studies, recommendations from the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC), evidence-based guidelines, professional society position statements, expert opinion, and public comments.

 

The overall objective for the critical appraisal of the evidence is to determine to what degree we are confident that: 1) specific clinical question relevant to the coverage request can be answered conclusively; and 2) the extent to which we are confident that the intervention will improve health outcomes for patients.

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CMS staff extensively searched for primary studies evaluating therapeutic interventions for gender dysphoria. There was particular emphasis on the various surgical interventions, but other treatments including hormone therapy, psychotherapy, psychiatric treatment, ancillary reproductive and gender modifying services, and post-operative surveillance services for natal sex organs were also included because of their serial and sometimes overlapping roles in patient management. The emphasis focused less on specific surgical techniques and more on functional outcomes unless specific techniques altered those types of outcomes.

 

The reviewed evidence included articles obtained by searching literature databases and technology review databases from PubMed (1965 to current date), EMBASE, the Agency for Healthcare Research and Quality (AHRQ), the Blue Cross/Blue Shield Technology Evaluation Center, the Cochrane Collection, the Institute of Medicine, and the National Institute for Health and Care Excellence (NICE) as well as the source material for commentary, guidelines, and formal evidence-based documents published by professional societies. Systematic reviews were used to help locate some of the more obscure publications and abstracts.

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CMS reviewed and considered potential objective measures of function including mortality, psychiatric treatment, and attempted suicide. None of the longitudinal studies in which patients served as their own control, however, comprehensively tracked changes in these events as objective measures of function before and after surgery. Events such as suicide and institutionalization were mentioned incidentally when describing patients excluded from a follow-up study or during the study (Heylens et al., 2014; Ruppin, Pfafflin, 2015). Other times investigators tracked these functional outcomes (e.g., psychiatric out-patient treatment, psychiatric in-patient treatment, and substance abuse) for the most current prior year (Ruppin, Pfafflin, 2015).

 

The most comprehensive study with functional endpoints, the Swedish study that followed all patients who had undergone reassignment surgery (at mean age 35.1 years) over a 30 year interval and compared them to 6480 matched controls, identified increased mortality and increased psychiatric hospitalization (Dhejne et al., 2011). The mortality was primarily due to completed suicides (19.1-fold greater than in control Swedes), but death due to neoplasm and cardiovascular disease was increased 2 to 2.5 times as well. The divergence in mortality from the Swedish population did not become apparent until after 10 years. The risk for psychiatric hospitalization was 2.8 times greater than in controls even after adjustment for prior psychiatric disease (18%). The risk for attempted suicide was greater in male-to-female patients regardless of the gender of the control. Unfortunately, the study was not constructed to assess the impact of gender reassignment per se. The finding of this study, again, demonstrated that reassignment surgery does not return patients to a normal level of morbidity risk and that the morbidity risk is significant, because of its clinical importance, its persistence over the interval of data collection and the increase in risk over time for the individual.

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The currently available evidence has limitations:

 

  • There were design deficiencies. All but one of the studies were observational in nature. All but two were non-blinded. The accompanying loss to follow-up suggests that there is selection bias and that the population that seeks treatment for gender dysphoria is not the same population that undergoes reassignment surgery without hesitation or regret.
  • The psychometric and psychosocial function endpoints are not well validated.
  • There were limitations of the psychosocial endpoints and of the data collection of other hard functional outcomes. Evidence on mortality and especially suicide was stronger. The mortality and psychiatric hospitalization rates even after vetting in highly structured programs are of concern.
  • There are insufficient data to select optimal candidates for surgery.
  • The results were inconsistent, but negative in the best studies, i.e., those that reduced confounding by testing patients prior to and after surgery and which used psychometric tests with some established validation in other large populations. (Atkins et al., 2004; Balshem et al., 2011; Chan, Altman, 2005; Deeks et al., 2003; Guyatt et al., 2008a-c; 2011a-e; Kunz, Oxman,1998; Kunz et al., 2007 and 2011; Odgaard-Jensen et al., 2011).

Data on reassignment surgery performed on geriatric patients or follow-up data in geriatric patients who had reassignment surgery in the distant past is anecdotal (Orel, 2014).

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Based on a thorough review of the clinical evidence available at this time, there is not enough evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria. There were conflicting (inconsistent) study results – of the best designed studies, some reported benefits while others reported harms.

 

The quality and strength of evidence were low due to the mostly observational study designs with no comparison groups, potential confounding and small sample sizes. Many studies that reported positive outcomes were exploratory type studies (case-series and case-control) with no confirmatory follow-up. Due in part to the generally younger and healthier study participants, the generalizability of the studies to the Medicare population is also unclear. Additional research is needed. This proposed conclusion is consistent with the West Midlands Health Technology Assessment Collaboration (2009) that reported “[f]urther research is needed but must use more sophisticated designs with comparison groups.” WPATH also noted the need for further research: “More studies are needed that focus on the outcomes of current assessment and treatment approaches for gender dysphoria.” Further, as mentioned earlier, patient preference is an important aspect of any treatment. With that in mind, CMS is interested in knowing from the patients with gender dysphoria what is important to them as a result of a successful gender reassignment surgery.

 

Knowledge on gender reassignment surgery for individuals with gender dysphoria is evolving. The specific role for various surgical procedures is less well understood than the role of hormonal intervention. Much of the available research has been conducted in highly vetted patients at select care programs integrating psychotherapy, endocrinology, and various surgical disciplines and operating under European medical management and regulatory structures. Standard psychometric tools need to be developed and tested in the patients with gender dysphoria to validly assess long term outcomes. As such, further evidence in this area would contribute to the question of whether gender reassignment surgery improves health outcomes in adults with gender dysphoria.

 

Because CMS is mindful of the unique and complex needs of this patient population and because CMS seeks sound data to guide proper care of the Medicare subset of this patient population, CMS strongly encourages robust clinical studies with adequate patient protections that will fill the evidence gaps delineated in this decision memorandum.

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Currently, the local Medicare Administrative Contractors (MACs) determine coverage of gender reassignment surgery on an individual claim basis. The Centers for Medicare & Medicaid Services (CMS) proposes to continue this practice and not issue a National Coverage Determination (NCD) at this time on gender reassignment surgery for Medicare beneficiaries with gender dysphoria. Our review of the clinical evidence for gender reassignment surgery was inconclusive for the Medicare population at large.

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Read the complete evidence review and text of Medicare’s denial of a national coverage determination for ‘Gender Reasignment Surgery” here:

https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=282

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23 Responses to “Medicare denies national coverage for gender reassignment surgery: No evidence of therapeutic outcome”

  1. dejavublonde Says:

    wow, my initial response is ‘this is a REALLY BIG FUCKING DEAL!”. my cynical side kicks in with: will they maintain this position? will this position in its entirety become public knowledge? Beyond the ‘scream scream scream’ reaction the trans take to just about everything, will they really care about this as the current thing to do is NOT try to pass in any way except giant bolt-on boobs? I WANT this to be a really big deal but I fear it won’t be.

  2. wildwomyn Says:

    Thank goodness! I just signed up for Medicare and I don’t want dollars from this beleaguered (by the Republicans) program to be used for unnecessary services. Old autogynophiles wanting to prey on us older Lesbians. Good thing that they still look like old men in drag anyway.

    • Margie Says:

      True. Sadly, we already pay for the “transitioning” of some of these people, the criminals. I just read a really horrifying article about one of California’s most notorious murderers, Skylar DeLeon. He brutally murdered a retired couple for their houseboat, which he was going to sell in order to fund his surgery. He used his pregnant wife as a prop to gain the couple’s confidence, and then he trapped and killed them. (I will spare you the details, which are horrible.) He wanted that boat to pay for the surgery, but since that failed, he wants CA taxpayers to pay for it.

      • disarminglyastute Says:

        Ugh, I remember watching a program covering the murders committed by DeLeon, and the reporters mentioned NOTHING about him wanting to use the money to transition – figures. Part of me wonders if he decided to transition after the fact, to try to get into a women’s prison, as others have done before him.
        Isn’t it Medicaid that has paid for these procedures for prisoners in the past?

      • Margie Says:

        @Disarminglyastute – It wouldn’t be Medicaid but rather money in the CA Department of Corrections budget for prisoner health care. So CA money, not federal money would be used to pay for his surgery. He and his lawyers definitely kept the transgender angle quiet during his trial, but after he was sentenced it suddenly came out. Now he admits that the murder/yacht theft scheme was all driven by his need for money for surgery. Funny how this has received zero coverage on the “LGBT” propaganda blogs.

    • kesher Says:

      Surgery in older people leads to greater complications due to susceptibility of infection and longer recovery times. It is truly mind boggling that the trans cult thought it could get away with recommending boob jobs and penis inversions for elderly men.

  3. Margie Says:

    Yay! This will really piss them off, which is a bonus! BTW, it is good to see you back Gallus. I was starting to get worried. I hope that you were taking a vacation or doing something fun.

  4. rheapdx1 Says:

    When I first read the above posting, let’s say most of this part of town heard my reaction😊 Then in reading through a couple more times, it became apparent that the system gamers have met the brick wall.

    ‘The Wall’ being that with no actual, verifiable via acceptable, standard means….the fed will not offer blanket coverage for what are essentially cosmetic, elective medical work. On an individual basis, maybe…..but the evidence in examining said patient would have to make a damn good case for same. Be it about any problems with pre-existing medical conditions or mental health ones. And it is the latter that needs to really be scrutinized. After all…how many posts here supplied by @GallusMag and others have shown that more often than not, there are those getting the work done who were unstable before, just the same…if not more unhinged after? More than I can count right now.

    By the way, when one reads between the SJW lines or views the optics…the ones pushing the surgery coverage, also want the fed to deny or curtail needed medical work for ‘undesirables’. This is of course, barring that said undesirable meets with the accepted stereotype(s). No person in the trans silo, if they were honest can deny that. This ruling, if followed can expose that more to the light of day ..as it has how flaws and falsehoods that were used to justify the cases for the electives.

    Something says that the whiner brigade will try to censor this. No different than other groups try to establish pivots obscure anything that goes against their flawed mantra. The few who do not buy into this crap…did things the right way, while understanding the limitations have been vindicated. Perhaps the tide is turning against those who wanted the game the system, like cheaters in other arenas.

    • GallusMag Says:

      “Something says that the whiner brigade will try to censor this. ”

      No one else has covered this. Total media blackout.😉

      • rheapdx1 Says:

        At some point, there may be abpart of the ‘established’ media that will pick up on this. If not, perhaps this may be a connection/adjunct to the cases being filed re: the lavs, Title IX protections, etc.

        Put another way….the peak has been reached, with the mountain being made of cow dung. Or the pyramid scheme is collapsing, layer by layer. There are other metaphors, but one gets the idea.

  5. GallusMag Says:

    Guess they can’t blame Janice Raymond for this one.

    • Medi Says:

      Your one liners just crack me up Gallus! Thanks I really need your humor today!

    • rheapdx1 Says:

      @GallusMag Speaking of Janice….there was another attack made on her and her writings in another space, which again gives one pause. As in….when one reads the comments, one sees that what she and others bring up in the way of facts are attacked and ridiculed, if they are not in line with mass delusion.

      Yep….the high school clique level of behavior is still in session. Little do they of the emotional and socially stunted via HRT cocktails minds get, is that even though there is respect for expressing whatever, the lies have a short shelf life. The damage done by these folks to their own…and others…does not.


  6. Gallus, this is confusing, but what the government does usually makes no sense at all. So, there is no National Coverage Determination, but local Medicare Administrative Contractors can cover sex reassignment surgery on an individual basis.

    As I understand it based on a quick google search, local Medicare Administrative Contractors are private insurance companies that contract with Medicare.

    “Currently, the local Medicare Administrative Contractors (MACs) determine coverage of gender reassignment surgery on an individual claim basis. The Centers for Medicare & Medicaid Services (CMS) proposes to continue this practice and not issue a National Coverage Determination (NCD) at this time on gender reassignment surgery for Medicare beneficiaries with gender dysphoria….

    In the absence of a NCD, initial coverage determinations under section 1862(a)(1)(A) of the Social Security Act (the Act) and any other relevant statutory requirements will be made by the local Medicare Administrative Contractors (MACs) on an individual claim basis..”

    “Our review of the clinical evidence for gender reassignment surgery was inconclusive for the Medicare population at large. The low number of clinical studies specifically about Medicare beneficiaries’ health outcomes for gender reassignment surgery and small sample sizes inhibited our ability to create clinical appropriateness criteria for cohorts of Medicare beneficiaries.”

    Medicare is for the elderly and disabled not the general population. Original Medicare won’t pay for basic necessities such as dental work or eye glasses. That is, Medicare alone as opposed to some type of Medicare Advantage private health care policy that seniors have to pay extra for out of their own pocket. Seniors need dentures and eye glasses more than grandpa needs a sex change. If grandpa has lived sixty plus years without a sex change operation, he really doesn’t need one now. There is no large body of research anywhere that shows that the benefits of sex reassignment surgery in the Medicare population outweigh the numerous risks associated with these drastic surgeries on otherwise healthy genitals and reproductive systems. We are talking about surgery on elderly and disabled people who already have numerous chronic health problems. For all practical purposes, sex reassignment surgery is elective surgery. A botched SRS like this one could end up costing Medicare a boat load of money.

    http://bilerico.lgbtqnation.com/2010/06/sex_reassignment_surgery_when_things_go_wrong.php

    FTM “top surgery” and “bottom surgery” is rather ghastly.

    https://gendertrender.wordpress.com/2014/03/16/if-the-nipple-falls-off-just-throw-it-in-the-garbage-when-ftm-top-surgery-goes-wrong/

    http://www.dailymail.co.uk/news/article-2440086/Belgian-transsexual-Nathan-Verhelst-44-elects-die-euthanasia-botched-sex-change-operation.html

    https://gendertrender.wordpress.com/tag/nathan-verhelst/

    There is also the ethical issues involved in mutilating the genitals and breasts of disabled people, and sterilizing disabled individuals. This has such a nasty history, and does the government really want to take this on. Millions of disabled people are on Medicare, and is the government saying that all disabled people on Medicare are capable of knowing whether or not they want their genitals surgically altered? People who read gendertrender know that disabled people, especially young disabled women are being “transitioned”. Indeed, trans activists see no problem in “transitioning” just about any disabled person.

    A developmentally disabled woman with Down Syndrome who was in the ICU with a life threatening pulmonary embolism doesn’t need “top surgery”.

    https://gendertrender.wordpress.com/2015/08/21/aydin-olson-kennedy-msw-urges-gender-surgery-for-down-syndrome-child-in-intensive-care-unit/

    Mentally ill women with bipolar disorder don’t need to be “transitioned”.

    https://gendertrender.wordpress.com/2016/02/14/gender-blah/

    This disabled young woman with autism underwent “top surgery” after only two visits to the “gender therapist”. Apparently, her mother’s insurance paid for it, but if trans activists had their way, Medicare (the government) would be paying for elective mastectomies for disabled women with autism. Two visits to the “gender therapist”, and it’s off to the surgeon. Don’t tell me it won’t happen because they have proven time and time again that they will “transition” anyone.

    “To give you some sense of my daughter’s level of understanding of what it means to transition, she told me recently that she believes that the testosterone “will grow her a penis.” I had to break the news to her that, although this is the mythology in the PFLAG meetings (where a number of the other young trans people are also autistic), this is not the case…

    She has been taken advantage of. Healthy organs were amputated. This is insurance fraud, poor clinical practice, a violation of APA standards, unethical and unjust. It is a crime not just against women, but particularly against disabled women. So many of these young women who are “transitioning” are also autistic….

    My daughter has a representative payee on her SSDI [disability] check, as it was felt that she was unable to handle her own money. This was of little concern to the gender therapist. I believe that once the therapist realized the “treatment” would be covered by the University of Michigan insurance, it was full speed ahead.”

    https://4thwavenow.com/2016/05/06/social-work-prof-speaks-out-on-behalf-of-her-ftm-autistic-daughter/

    Not only is “the review of the clinical evidence for gender reassignment surgery inconclusive for the Medicare population at large”, there are ethical issues involved in mutilating the genitals of disabled people. Moreover, most “gender therapists” are nothing but frauds. “Gender identity” is nothing but a subjective diagnosis that can’t be proven one way or another.

  7. Bob Doublin Says:

    Getting this published showing the research and previously published reports- setting it clearly is important,even if it lies hidden for awhile. It’s here on your site and that’s important also. Your place is a gold mine of information.

  8. Toots Says:

    indiviual states have changed their Medicaid policies to cover SRS. They cover it in my state and the state below us does also.

  9. Bev Jo Says:

    Fantastic, if only it holds….

  10. IronBatMaiden Says:

    Looks like the medical community is waking up. We don’t need to pay for shit like this. We need to fight to win the battle for women’s reproductive rights once and for all! It sickens me that this battle has been going on for over 40 fucking years!! It’s about time to finally beat it once and for all.

    • georgiaswann Says:

      I still am in disbelief that women are denied access to the procedures we need. We are afterthoughts when it comes to medical research. Yet middle aged male psychopaths want free vaginas for everyone!!!! Is this real life? Next week the furries will want to start identifying as the animal they feel they are on the inside! Will doctors help them grow tails?

      • IronBatMaiden Says:

        We need to come together and fight like hell to make sure the politicians don’t take that away. Even if we have to go underground again, we will continue on. When will right wig numbskulls get it through their fucking heads that banning abortions doesn’t stop it? It only creates more and results in more women dying.


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