Sunday, October 23, 2022

Side Note: New 2022 Review, History of Transgender Surgery; Medicare Notes

The new October issue of Annals of Internal Medicine has a long historical article, and an accompanying Op Ed, on the history of transgender surgery in the US.   See Magrath WJ, 2022, "The fall of the nation's first gender-affirming surgery clinic," here.   See also Keuroghlian AS & Radix AE, "A cautionary tale: The doomed gender identity clinic at Johns Hopkins Hospital," here.   They discuss the history of the transgender surgery center at Johns Hopkins, which closed in 1979.


Not mentioned are the Medicare policy tie-ins, which I'll just annotate briefly.   


Medicare had no national policy on gender surgery until 1989, when it introduced a negative NCD, based on a extremely faulty "technology assessment" of the time (1980/1981).  (So this was a couple years after the Hopkins event and in Year 1 of the Reagan administration).  The negative NCD was published ;ater in 1989 as a few paragraphs in the Federal Register (August 1, 1989; Fed Reg 54:34555, at 34572.)  Here.  JPEG at bottom of this blog.


This 1989 NCD was thrown out by a panel of administrative law judges in 2013/2014, which I covered in a detailed blog in May 2014 here.  

(My 2014 blog notes that I had seen an optical character reading (OCR) version of the 1980/81 tech assessment, but the blog was edited by me to note that this had become a dead link in 2016. I don't seem to have a hard drive copy of that tech assessment, but in appears in bibliographies of academic articles on this Medicare history and in a discussion here.)   


Since the NCD was active 1989-2014, when it was thrown out, CMS had no national statement on transgender surgery for a couple years.  

In 2016, CMS released a draft, and then final, NCD, that said that transgender surgery was a local MAC decision.  (Blog from June 2016 here).  NCD 140.9 homepage here.  

While the draft and final decisions in 2016 both left coverage to the MAC level, there were  substantial redlines between the draft and final.  Click to enlarge:

2016 (redline draft v final)