Resources

Transgender Medical Treatment: Medically Necessary and Not Cosmetic

This page is part of a set of resources for employers to implement transgender-inclusive health insurance coverage. See "Transgender-Inclusive Benefits for Employees and Dependents" for the complete set of resources.

4/28/2010

Health insurance providers with less restrictive or intentionally inclusive policies have denied insurance claims for transgender-related care on the grounds that a treatment or procedure is "cosmetic," "experimental" or not "medically necessary." However, treatment provided by health professionals -- in accordance with the World Professional Association for Transgender Health's Standards of Care -- should be considered medically necessary, reconstructive and not cosmetic.

Decades of experience with the WPATH Standards of Care show that gender transitions and related care are accepted, good medical practice and effective treatment.

"Sex reassignment, properly indicated and performed as provided by the Standards of Care, has proven to be beneficial and effective in the treatment of individuals with transsexualism, gender identity disorder, and/or gender dysphoria. Sex reassignment plays an undisputed role in contributing toward favorable outcomes, and comprises Real Life Experience, legal name and sex change on identity documents, as well as medically necessary hormone treatment, counseling, psychotherapy, and other medical procedures...

"The medical procedures attendant to sex reassignment are not "cosmetic" or "elective" or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition."
— WPATH Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A.[1]

What Does "Medically Necessary" Mean?

Most definitions of medical necessity are generally vague. One state employees' health and prescription drug benefits plan defines it as follows:

"Medically Necessary care and treatment is recommended or approved by a Physician; is consistent with the patient's condition or accepted standards of good medical practice; is medically proven to be effective treatment of the condition; is not performed mainly for the convenience of the patient or provider; is not conducted for research purposes; and is the most appropriate level of services which can be safely provided to the patient."[2]

 

 

[2] WPATH Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A. (obtained July 2008). Available at: http://www.wpath.org/documents/Med%20Nec%20on%202008%20Letterhead.pdf.

[1] State of Connecticut Teachers' Retirement Board Health and Prescription Drug Benefits Plan for 2006 (obtained 2008). Available at: http://www.ct.gov/trb/lib/trb/formsandpubs/SPD_2006WEB.pdf.