Allison Escolastico, a 30-year-old transgender woman, has wanted breast augmentation surgery for a decade. By 2019, she finally thought her insurance company, Aetna, would pay for it, only to find that it considered the procedure cosmetic, not medically necessary, and refused to cover it.
“I knew from my case, it wasn’t cosmetic,” said Ms. Escolastico, who contacted a lawyer after she lost her appeal last year. “I knew I had to fight for this,” she said.
Ms. Escolastico’s surgery is now scheduled for February. Working with the Transgender Legal Defense and Education Fund, a nonprofit that advocates transgender rights, and Cohen Milstein Sellers and Toll, a large law firm that represents plaintiffs, she and a small group of trans women persuaded Aetna to cover the procedure if they can show it to be medically necessary.
To qualify, the women would need to demonstrate that they had persistent gender dysphoria, undergo a year of feminizing hormone therapy and have a referral from a mental health professional.
The shift by Aetna represents an important evolution in how health insurers view the medical needs of transgender individuals. While some insurers offer a broad range of surgeries for trans women if they are deemed medically necessary, others exclude breast augmentation and other treatments as merely cosmetic.
“This has the potential to be a transformative moment,” said Kalpana Kotagal, a partner at Cohen Milstein.
Insurers have typically covered genital reassignment surgery as medically necessary. But transgender women and others say breast augmentation is also a necessary treatment for individuals who receive a diagnosis of gender dysphoria. “There is no question from a medical perspective,” said Noah E. Lewis, the director of the Trans Health Project at the fund.
The New York Times