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. Supreme Court upholds state-level ban on transgender surgery for minors, here.
I noted recently that a MAC has newly updated an LCD to avoid disallowed use of the word "gender."
What about Medicare 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. (2014 legal record). 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.
Medicare MAC Billing & Coding for Gender Dysphoria
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.
Utilization. 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 the subsequent 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 word search of whether words like "diversity" or "equity" appear 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. See also a court order.)
On that theme, 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" (attributed to 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%). Or, if a study in an area with 50% black population must enroll no more than 15%, the national rate.)
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, will 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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