By Joan Chang, Senior Attorney, Health Unit
Alicia (fictitious name) is a 34-year-old male to female transgender individual who, when facing multiple barriers accessing gender-affirming surgeries, contacted Community Legal Aid SoCal’s Health Unit for help.
Covered by Medi-Cal/CalOptima, Alicia had seen an out-of-network plastic surgeon. Dr. Dey (fictitious name), a board-certified surgeon, is transgender herself and well-experienced in evaluating, treating, and operating on transgender patients. After a medical assessment, Dr. Dey recommended that Alicia undergo surgery to alleviate the gender dysphoria she was suffering.
CalOptima found that Alicia met the World Professional Association for Transgender Health’s (WPATH) guidelines for breast/top surgery. However, they denied the request for trach/larynx surgery, facial feminization, and body contouring because they determined that, based on a series of standards, the surgeries were not medical necessities.
Health Unit senior attorney Joan Chang represented Alicia at the state hearing to challenge CalOptima’s denial. CalOptima attempted to argue that it was a late hearing request, however Joan pushed back and provided legal citation and language that the request was indeed timely made, especially considering the Public Health Emergency extensions. On behalf of Alicia, Joan argued that:
- Facial feminization and body contouring surgeries are medically necessary to treat Alicia’s gender dysphoria.
- CalOptima failed to comply with the California Department of Health Care Services’ notice of action requirements.
- Alicia meets CalOptima’s own policy on “sex reassignment surgery.”
- CalOptima improperly relies on proprietary Milliman Care Guidelines as law.
- WPATH identifies Alicia’s denied surgeries as “medically necessary” gender-affirming surgical procedures.
- CalOptima failed to provide sufficient time to utilize the approved authorizations.
- The surgical procedures should be performed by the originally approved surgeon, Dr. Dey, and not re-directed to the University of California San Diego.
The denied services included four categories of gender affirming surgeries and consequently the hearing process was four times as long and complex (three state hearings, testimony and cross of two medical experts, numerous hearing briefs and supplemental briefs, extensive medical and legal research, research of numerous clinical studies, re-reviews from CalOptima’s “independent medical reviewer”, and written and oral rebuttals).
The outcome of the hearing was a big relief for an overjoyed Alicia. Thanks to CLA SoCal’s Health Unit and Joan’s advocacy, the administrative law judge found in Alicia’s favor and determined that it is necessary for her to undergo gender-affirming procedures. The administrative law judge also approved the request to have the preferred out-of-network provider Dr. Dey perform the surgeries.
