Victory! Transgender Woman Wins Coverage for Breast Reconstructive Surgery in California

When Kenna Fisher looked through her health plan two years ago, she was disturbed to see that it had specific exclusions – and that they mostly applied to transgender women. A transgender woman and librarian who works at UC Berkeley, Kenna says that the exclusions just didn’t strike her as right. “My treatment should be based on what I need,” says Kenna, “not what someone else feels is the right or wrong way to transition.”

This month Kenna, represented by Transgender Law Center, won a groundbreaking health care appeal affirming just that: an insurer cannot deny her breast reconstructive surgery (breast augmentation surgery) simply because she is transgender.

The victory created precedent within the California insurance appeals system that will help establish that all care for gender dysphoria must be individualized for transgender patients and that breast reconstructive surgery can be medically necessary for transgender people. The decision will also serve as a national model, and makes clear that individualized assessment for patients is in line with evidence-based medicine practices.

“I’ve been working on this for two years, and it’s been a struggle the whole way,” says Kenna. “I’m so glad that this victory means there’s a template out there for other women.”

More and more insurance providers across the country are removing their categorical exclusions for some treatments, but continue to deny coverage for other procedures that may be life-saving for some transgender people. In determining that our client’s request was indeed valid, the Independent Medical Reviewer made special note that the client’s breast development was consistent with an early stage of puberty (Tanner stage 2), and therefore did not represent a level of development expected in an adult woman.

Our work in California will provide a template for ensuring people have access to individualized care. The victory built on the landmark All-Plan Letter issued earlier this year by the California Department of Managed Health Care, which prohibits insurers from categorically excluding specific treatments for transgender people. Transgender Law Center worked closely with the Department of Managed Health Care on this clarification, which builds on the department’s 2013 director’s letter that banned discrimination against transgender and gender non-conforming people in health insurance.

If you’re interested in learning more about our work on this case, you can read the documents here.