Aetna to broaden gender affirming surgery insurance coverage

Gender affirming surgery insurance - surgeon with breast implant

This national health insurer has agreed to cover some trans women’s breast augmentation.

Aetna recently agreed to cover gender affirming surgery insurance in the form of breast augmentation for some trans women patients.

Many trans women have struggled to obtain this coverage which is often labeled as cosmetic.

This change in gender affirming surgery insurance attitude was in part the result of a case with a 30-year-old transgender woman named Allison Escolastico. She had been seeking breast augmentation surgery for ten years and had been under the impression that Aetna, her insurance company, would cover it in 2019. That said, the insurer refused, deeming it not medically necessary as they labeled it a cosmetic procedure.

“I knew from my case, it wasn’t cosmetic,” said Escolastico in a recent New York Times report. Her next step was to contact a lawyer following the loss of her appeal of the refusal. “I knew I had to fight for this,” she explained.

The lawyer worked with a transgender rights advocate group for the the gender affirming surgery insurance coverage.

Escolastico’s lawyers from the large law firm of Cohen Milstein Sellers and Toll worked with the non-profit transgender rights advocate group Transgender Legal Defense and Education Fund. Together, they persuaded Aetna to provide the coverage provided they could show that it was medically necessary to Escolastico. The patient’s surgery has now been scheduled for next month.

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In order to qualify to have these procedures covered, transgender women must be able to demonstrate that they have experienced persistent gender dysphoria. They must also have undergone a minimum of a year of feminizing hormone therapy and must provide a mental health professional’s referral.

Aetna’s change of course is viewed as an important shift in the way health insurance companies interpret the medical requirements of transgender people. Though some offer a wide spectrum of surgery coverage for trans women provided they are determined to be medically necessary, others will exclude surgeries such as breast augmentations, which they label as nothing more than cosmetic.

Gender affirming surgery insurance - surgeon with breast implant“This has the potential to be a transformative moment,” said Cohen Milstein partner Kalpana Kotagal following Aetna’s decision to provide the transgender affirming surgery insurance coverage.

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