Allison Escolastico, a 30-year-old transgender woman, has wanted breast augmentation surgery for a decade. In 2019, she finally thought her insurance company, Aetna, would pay for it, only to find that she viewed the procedure as cosmetic, not medically necessary, and refused to cover it.
“I knew my case wasn’t cosmetic,” said Escolastico, who contacted a lawyer after losing her appeal last year. “I knew I had to fight for this,” she says.
Ms Escolastico’s surgery is now scheduled for February. Working with the Transgender Legal Defense and Education Fund, a non-profit organization that advocates for transgender rights, and Cohen Milstein Sellers and Toll, a large law firm that represents plaintiffs, she and a small group of trans women have persuaded Aetna to cover the procedure if they could show it must be medically necessary.
To be eligible, women would need to demonstrate that they have persistent gender dysphoria, undergo one year of feminizing hormone therapy, and be referred by a mental health professional.
Aetna’s change represents a significant shift in the way health insurers perceive the medical needs of transgender people. While some insurers offer a wide range of surgeries for trans women if deemed medically necessary, others exclude breast augmentation and other treatments as simply cosmetic.
“This has the potential to be a moment of transformation,” said Kalpana Kotagal, partner at Cohen Milstein.
Insurers have generally covered genital reassignment surgery as medically necessary. But transgender women and others say breast augmentation is also a necessary treatment for people who are diagnosed with gender dysphoria. “There’s no question from a medical point of view,” said Noah E. Lewis, director of the fund’s Trans Health project.
In addition, he said, it is illegal for a health insurer to deny health care coverage because of a person’s gender identity. “It’s a very simple discrimination issue,” he said.
Aetna, who is owned by CVS Health, had been actively reviewing the need for breast augmentation surgery for trans women, said Dr Jordan Pritzker, senior director of clinical solutions for the insurer. He said he had spoken to many doctors who perform the surgery.
“Our decision to update our Clinical Policy Bulletin is in line with many changes we have made over the years to better meet the needs of the LGBTQ community,” Dr. Pritzker said in a statement.
Aetna said she would also reimburse some transgender women who were denied coverage but had surgery. The company said it is actively reaching out to people who have applied for clearance for their surgeries and been denied.
Cora Brna was denied coverage for breast augmentation surgery two years ago when she tried to schedule it at the same time she was undergoing genital reassignment, which was covered by Aetna. “I was devastated,” she says.
“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 care worker in Pittsburgh and was one of the women who petitioned Aetna. She had genital surgery but only had the breast augmentation procedure after being covered by a different health plan.
Aetna’s new policy also comes at a time when the federal government is reconsidering whether denying certain types of care to transgender people is discriminatory. Under the Affordable Care Act, insurers cannot discriminate against individuals on the basis of gender identity, and most insurance companies provide coverage for people who require gender reassignment surgery. But the law never mandated a specific benefit or detailed exactly what services insurers would cover, said Katie Keith, who teaches law at Georgetown University and follows this area of the law closely.
“It’s almost like a parity issue,” she says.
While the Trump administration sought to overturn protections for transgender people with a rule last June, the issue is still being resolved in the courts, said Ms Keith, who also highlighted the recent court ruling. supreme that gay and transgender workers are protected. discrimination in the workplace under civil law.
The new Biden administration has already issued an executive order saying it will enforce civil rights laws that protect people from discrimination on the basis of gender identity.
The major insurance companies are uneven in their coverage. Health Care Service Corp., which offers Blue Cross plans in five states, will pay for breast augmentation and other services for trans women if they are deemed medically necessary. The insurer said it developed these policies in accordance with guidelines set by the World Professional Association for Transgender Health, a non-profit organization.
But other big insurers, including Anthem and UnitedHealthcare, continue to view surgery as cosmetic, as they typically don’t cover procedures for women without a diagnosis of gender dysphoria. They say they don’t discriminate against trans women.
Anthem states that “its medical policy is applied fairly to all members, regardless of their sex or gender identity.”
And UnitedHealthcare said in a statement that its “coverage for the treatment of gender dysphoria is comprehensive and, depending on member benefit plans, current coverage may include doctor visits, mental health services, prescription drugs and surgery to treat gender dysphoria. He added that he uses “evidence-based medicine to make coverage policy decisions,” which are updated regularly.
But lawyers for the women involved in the Aetna deal say they are looking closely at the policies of other insurers to see if they can argue that their refusal to offer coverage is discriminatory. “This is something that needs to be changed throughout the industry,” said Ms. Kotagal of Cohen Milstein.