Update and clarification on Medicare coverage.
I have been in touch with the woman responsible for getting the blanket ban on transgender medical procedures lifted. I am also in the process of extensive research on the current state of affairs.
The 2014 decision to lift the blanket down on the national coverage decision triggered a review of whether or not a national coverage policy should be given to gender reassignment surgery for for those medications that suffer from gender dysphoria.
The proposed recommendation as of now is to not issue an NCD and leave the authorizations to the regional MACs. This is based on their conclusion that positive, beneficial, and therapeutic outcomes can not be determined by their body of research collected and analyzed.
Where is the 20014 decision relied on expert testimony, and recognized standards of care by the transgender medical community and also took into account the changes in both technique, efficacy, and acceptance as an effective , safe, and necessary procedure for those with severe gender dysphoria. The 2014 decision also took into account the weight of evidence before and after 1981.
The current proposed decision for a NCD does not weigh this evidence appropriately, does not recognize the wpath SOC and medical necessity as proven, effective and mainstream within the transgender medical community. In fact the WPATH standards of care and Medical Necessity documentation is not part of the body of evidence used to determine a NCD.
2014 blanket ban lift
http://stateofreform.com/wp-content/uploads/2014/06/hhs-appeals-board-medicare-transgender-patient-care-5-30-14.pdf
Current proposed decision - boy that's a long read!
https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=282
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I am starting a project that is intended to help create a national coverage policy for transgender surgical procedures by Medicare.
My goal is to reverse engineer the Wpath SOC and criteria for medical necessity. At this point I am collecting the white papers, as well as specific published peer reviewed articles and studies that influenced the current standards of care for WPATH as well as justified the medical necessity for all transgender related care and procedures currently listed and discussed in The WPATH statement of medical necessity.
From that point I intend to create a new white paper to influence the national coverage policy for medical necessity services and procedures covered by Medicare to be determined, guided, and governed by WPATH criteria and SOC.
I also intend to look at current private, state, and exchange insurance policies and determine what research studies, white papers, and SOC guided them in determining medical Necessity for each specific covered service, and procedure as well as how they set the requirements, prerequisites, and reimbursement rates.
I intend to collect, organize, and make publicly available this research and resources to help create, and influence healthcare coverage and necessity as it relates to the care of transgender individuals.
I am just beginning this project, however I do have a very unique skill set that I've acquired over the past several years due to the need for coverage on multiple extremely rare conditions where no agreed upon treatment method or protocol is present. Due to this I have gone through the coverage determination process for services and procedure that has no coverage policy. I have become extremely effective at understanding what insurance carriers want and need to make a positive coverage decision.
In a way this situation with Medicare is a blessing. Considering that the data they used to determine their coverage policy recommendations is not aligned with the generally accepted effective treatments and protocols that the transgender healthcare community is using gives us ground to stand on. Medicare's own guidelines on creating a NCD policy dictates they use the best available research in the field, including but not limited to case studies, expert opinions, community recognized SOC for the treatment of the condition, and white papers. Because of these circumstances and policy requirements the work required, while time consuming, and slow is fairly easy and straightforward.
Any questions, feedback, further information, and additional resources are welcome!
Hugs,
~Brooke~