Aetna Expands Coverage to Include Breast Augmentation Surgery for Transgender Women

Aetna has agreed to expand coverage for gender-affirming procedures for transgender women, The New York Times reports.

Aetna, owned by CVS Health, will cover breast augmentation surgery for transgender women. This shift in coverage came about through a group of transgender women working with the Transgender Legal Defense and Education Fund, a nonprofit advocacy group for transgender rights, and Cohen Millstein Sellers and Toll's law firm. They convinced Aetna, as the Times reports, "to cover the procedure if they can show it to be medically necessary."

Those who qualify for the procedure must demonstrate contending with persistent gender dysphoria, undertake one year of feminizing hormone therapy, and be referred by a mental health professional.

Though genital reassignment surgery has been covered as medically necessary, most insurers still view breast augmentation as a cosmetic procedure, even if they offer a range of surgeries for transgender women. Advocates say it is necessary for those diagnosed with gender dysphoria.

Aetna says it has been reviewing its policies on breast augmentation surgery and consulting with surgeons. Dr. Jordan Pritzker, senior director for clinical solutions at Aetna, said that this is necessary in order "to better serve the needs of the LGBTQ community."

In 2019, Allison Escolastico – one of the transgender women who worked with Transgender Legal Defense and Education Fund and Cohen Millstein Sellers and Toll – was refused coverage for the procedure by Aetna, deeming it cosmetic. Escolastico's surgery is now scheduled for February 2020.

Aetna has also said that they are attempting to reimburse individuals who were initially denied coverage and paid out of pocket, such as Cora Brna, who ultimately had the surgery covered by another health plan. Brna, who applied for coverage two years ago and was denied, said, "I was devastated. I felt like a group of people were deciding whether I was or was not a woman."

Aetna's policy shift is happening as the federal government, under newly inaugurated President Biden, is looking into how healthcare policies can be discriminatory to transgender. Insurers cannot discriminate based on gender identity under the Affordable Care Act, and most providers cover gender reassignment surgery. However, the law does not mandate specific benefits and services. It remains illegal to deny medical care coverage based on gender identity.

Healthcare coverage for such procedures elsewhere in the world is virtually non-existent. Aysha Buffet, a popular drag queen and transgender woman in Melbourne, Australia – a country with a strong socialized public healthcare system that can be augmented by high-quality private insurance – started a GoFundMe campaign for Peritoneal Pull Through Vaginoplasty surgery, which is uncommon and unavailable in her home country.