Wednesday, June 08, 2016

What Is Going On Here?

Are we about to lose our Medicare insurance coverage? Reading this article in Modern Healthcare gives that impression that we are about to lose our coverage.
CMS may not pay for sex change operations, but the VA might
By Virgil Dickson
June 3, 2016

The CMS said there's not enough evidence to support Medicare payment for sex change operations. The decision came hours before the Veterans Affairs Department proposed covering sex-reassignment surgeries and other related medical treatment for transgender veterans.

The CMS didn't cover the surgery until 2014, when HHS' Appeals Board struck down a prior national coverage decision forbidding payment. That opened the door for Medicare's regional contractors to allow reimbursement.

In December, the agency announced it was considering a national coverage decision on surgery but now said it has decided the evidence was not there to support the move, according to a proposal released Thursday.

The agency said the clinical evidence was inconclusive for the Medicare population at large. “The low number of clinical studies specifically about Medicare beneficiaries' health outcomes for gender reassignment surgery and small sample sizes inhibited our ability to create clinical appropriateness criteria for cohorts of Medicare beneficiaries,” it said in the notice.
Whoa! “Not enough evidence”? What exactly do they mean? They held hearings and they reviewed the data about trans healthcare and now they are going to second guess themselves and make us go through this again?

The CMS proposal says,
Proposed Decision Memo for Gender Dysphoria and Gender Reassignment Surgery (CAG-00446N)

Decision Summary
Currently, the local Medicare Administrative Contractors (MACs) determine coverage of gender reassignment surgery on an individual claim basis. The Centers for Medicare & Medicaid Services (CMS) proposes to continue this practice and not issue a National Coverage Determination (NCD) at this time on gender reassignment surgery for Medicare beneficiaries with gender dysphoria.  Our review of the clinical evidence for gender reassignment surgery was inconclusive for the Medicare population at large.  The low number of clinical studies specifically about Medicare beneficiaries’ health outcomes for gender reassignment surgery and small sample sizes inhibited our ability to create clinical appropriateness criteria for cohorts of Medicare beneficiaries.

In the absence of a NCD, initial coverage determinations under section 1862(a)(1)(A) of the Social Security Act (the Act) and any other relevant statutory requirements will be made by the local Medicare Administrative Contractors (MACs) on an individual claim basis.

While we are not issuing a NCD, CMS encourages robust clinical studies that will fill the evidence gaps and help inform the answer to the question posed in this proposed decision memorandum.  Based on the gaps identified in the clinical evidence, these studies should focus on which patients are most likely to achieve improved health outcomes with gender reassignment surgery, which types of surgery are most appropriate, and what types of physician criteria and care setting(s) are needed to ensure that patients achieve improved health outcomes.

We are requesting public comments on this proposed decision memorandum pursuant to section 1862(l)(3)(a) of the Act. We are specifically interested in public comments on the evidence we cited in this decision, comments containing any new evidence that has not been considered, and comments on whether a study could be developed that would support coverage with evidence development (CED), which would only cover gender reassignment surgery for beneficiaries who choose to participate in a clinical study.
But if you read further it seems that they are not really taking away coverage but they want to include Gender Confirming Surgery (GCS) in their ruling from last year. It looks like last year’s statement did not specifically mandate GCS.
I. Proposed Decision
Currently, the local Medicare Administrative Contractors (MACs) determine coverage of gender reassignment surgery on an individual claim basis. The Centers for Medicare & Medicaid Services (CMS) proposes to continue this practice and not issue a National Coverage Determination (NCD) at this time on gender reassignment surgery for Medicare beneficiaries with gender dysphoria.  Our review of the clinical evidence for gender reassignment surgery was inconclusive for the Medicare population at large.  The low number of clinical studies specifically about Medicare beneficiaries’ health outcomes for gender reassignment surgery and small sample sizes inhibited our ability to create clinical appropriateness criteria for cohorts of Medicare beneficiaries.

In the absence of a NCD, initial coverage determinations under section 1862(a)(1)(A) of the Social Security Act (the Act) and any other relevant statutory requirements will be made by the local Medicare Administrative Contractors (MACs) on an individual claim basis.

While we are not issuing a NCD, CMS encourages robust clinical studies that will fill the evidence gaps and help inform the answer to the question posed in this proposed decision memorandum.  Based on the gaps identified in the clinical evidence, these studies should focus on which patients are most likely to achieve improved health outcomes with gender reassignment surgery, which types of surgery are most appropriate, and what types of physician criteria and care setting(s) are needed to ensure that patients achieve improved health outcomes.

We are requesting public comments on this proposed decision memorandum pursuant to section 1862(l)(3)(a) of the Act. We are specifically interested in public comments on the evidence we cited in this decision, comments containing any new evidence that has not been considered, and comments on whether a study could be developed that would support coverage with evidence development (CED), which would only cover gender reassignment surgery for beneficiaries who choose to participate in a clinical study.
Maybe this will loosen the purse strings on research into the effectiveness of GRS. In another article about this in Modern Healthcare Jennifer Levi form GLAD had this to say,
However, the board's decision didn't guarantee coverage for sex reassignment surgery. It gave individuals the right to submit physician documentation to local coverage contractors stating surgery was recommended in their individual case.

“The last step was about removing obstacles, this step is about creating a path to coverage,” said Jennifer Levi, a lawyer who directs the Transgender Rights Project of Gay & Lesbian Advocates and Defenders.

Some beneficiaries have been able to get surgeries since the ruling. But it's been a cumbersome process and taxing on providers who have had to navigate local coverage bureaucracies, transgender advocates say.
But no matter what it looks like we are going to have to fight for our insurance coverage. 

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