Medicare allows gender-changing surgery specifically at MAC discretion, based on a 2014-2016 legal case.
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We hear a lot in 2025 about gender dysphoria treatment. HHS released a report on this topic on May 1, 2025 (here). Quote, "Our duty is to protect our nation’s children—not expose them to unproven and irreversible medical interventions,” said NIH Director Dr. Jay Bhattacharya. “We must follow the gold standard of science, not activist agendas.” Find the 409-page HHS report here.
I noted recently that a MAC recently updated an LCD to avoid disallowed use of the word "gender."
What about NCDs and gender surgery?
NCD 140.9 was updated August 2016 to state that Gender Dysphoria and Gender Reassignment Surgery did not fall under an NCD any longer but rather was at the descretion of MACs (Medicare contractors) when medically necessary.
Medicare experts will recall, there was a pre-existing NCD that blocked gender surgery and there was a legal appeal of the NCD, and CMS did not fight the appeal. Instead, when the appellants "won," CMS revised the negative NCD and replaced it with the present NCD that makes gender surgery an elective decision of the MACs.
Palmetto MAC has a billing and coding article for Sexual Identity Dysphoria (A53793). While styled as a coding article, the article body is 1700 words long, with extensive discussions of medical necessity, definitions, processes, etc.
For example, code 57291, artificial vagina, was covered by Medicare about 80 times from 2013-2023 (based on AMA RBRVS DataManager). The data does not show how often it was a gender assignment issue.
See the NCD 140.9 here:
See my 2014 blog, "Judges reject decades-old ban on transgender surgery."
https://www.discoveriesinhealthpolicy.com/2014/05/judges-reject-decades-old-medicare-ban.html
See my 2016 blog on eventual updates to the NCD.
https://www.discoveriesinhealthpolicy.com/2016/06/cms-posts-draft-decision-on-gender.html
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Current Medicare Policies Citing Racial Groups
SCIENCE ran a detailed article on whether or not NIH centers had guidance on the hundreds of grant terminations based on words like "diversity" or "equity" appearing in the grants. Here. (If there ARE rules, they could be examined for appropriateness; if there ARE NO RULES, the NIH might be accused of arbitrariness.)
There are a number of Medicare policies that refer to race in various ways.
Glaucoma
42 CFR 410.23 covers screening for glaucoma, with special benefits enumerated for African-Americans and for Hispanic-Americans. These groups do not appear in statute (SSA 1861) and the racial groups were apparently added in regulation by CMS.
Alzheimer's
The NCD for studies of monoclonals directed against Amyloid requires that studies must have "A study population whose diversity of patients are representative of the national population with MCI" (AHRQ). The overarching coverage analysis refers to the Black racial group 12 times. (I wondered at the time how you could run a funded study in a state with a 1% Black population if you are required to match enrollment of that group as in the national population (~15%).)
Skin Cancer
An LCD examining coverage for biomarker testing in squamous carcinoma L39614, states that the test is non-covered and coverage for any population, would require that "further studies should include representation of test performance characteristics inclusive of and addressed in patients of color." (While noting that the majority of patients with SCC are the "Caucasian" population.)
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