Trans teen sues Premera after he was denied coverage of gender-affirming surgery [The Seattle Times]

Jul. 1—A trans teen and his family filed a federal class action lawsuit this week against a Washington health insurer after it repeatedly denied coverage of his gender-affirming surgery.

The complaint, filed Tuesday in the U.S. District Court's Western District of Washington, describes a months-long battle between Premera Blue Cross, based in Mountlake Terrace, and the family of a King County 15-year-old, identified in court documents as A.B. The lawsuit alleges Premera is violating sex and age discrimination laws in the Affordable Care Act by refusing to cover chest surgery — which A.B.'s providers agreed was medically necessary — for a trans patient under 18.

"This case highlights the nexus of issues our communities are facing," said Denise Diskin, one of the attorneys representing A.B. and his family, who is also executive director of QLaw Foundation, a Seattle-based legal nonprofit that works primarily with LGBTQ+ communities

"Trans youth are being placed in this deeply contested, minority status and having their voice and agency taken away on a national scale," Diskin continued. "There's this assumption and this mythology that [access to] trans youth health care is somehow sort of overreaching."

Premera, meanwhile, insists it supports access to gender-affirming care. The insurer says it has age limitations for many surgeries, not just gender-affirming procedures, including weight-loss and sleep apnea procedures.

However, the insurer doesn't apply age restrictions on similar top surgeries, including breast reductions, for youth who are cisgender (whose gender identity corresponds with the sex they were assigned at birth), A.B.'s attorneys argue.

"Our medical policy for gender-affirming services has been thoroughly researched and is based on the most current scientifically sound clinical evidence," Premera spokesperson Amanda Lansford said in a statement. "There is not strong evidentiary support for surgical interventions in minors."

Lansford declined to share copies of clinical evidence referenced.

According to the complaint, A.B. has identified as male since May 2021 and started hormone therapy in February 2022. He began struggling with chest binding, a practice used to compress breast tissue, until eventually his parents, therapist and doctors agreed that chest surgery, or a mastectomy, was necessary for his physical and mental health, the complaint says.

In early December, Premera — which covers A.B. through his father's plan — denied coverage based on A.B.'s age. The family appealed, but received another denial at the end of the month.

The family was particularly discouraged with the insurer, Diskin said, because they had also continuously requested internal records related to their case since late January but didn't receive any until June, after they had retained counsel.

According to the complaint, internal records show Premera's assistant medical director did review A.B.'s case and determined the teen didn't qualify as "an exception to the minimum age of 18" for gender-affirming chest surgery.

The director had several specific criteria he considered before granting an exception, including whether or not a chest binder was causing rib/skeletal injury or significant wounds, or if the patient was experiencing self-harm due to gender dysphoria (or distress when a person's gender identity doesn't match the sex they were assigned at birth).

A.B.'s attorneys called Premera's criteria "personal" and "seemingly arbitrary," and not in line with the World Professional Association for Transgender Health (WPATH) standards of care, health care guidelines for trans and gender nonconforming people developed by providers and patients. The guidance is generally regarded as best practice on gender-affirming care, Diskin said.

According to the most recent version of WPATH's guidelines, genital surgery should not be performed until patients reach the legal age of majority in a given country and they've lived continuously for at least a year in their preferred gender role — but chest surgery could be carried out earlier. The guidelines recommend mastectomies happen "preferably after ample time living in the desired gender role and after one year of testosterone treatment," but that different approaches could be recommended.

Researchers have extensively studied the topic of gender-affirming care for young trans people, with results consistently showing access to care is associated with better mental health outcomes — and that lack of access is associated with higher rates of self-harm and depression.

"There is no science that says this is not appropriate for someone who has met all the WPATH requirements, as this young person has," said Ele Hamburger, another attorney representing A.B. and his family. "If you follow the science, you cannot have a categorical exclusion like this."

The complaint also notes Premera's criteria for approving mastectomies for people under 18 is not public and wasn't shared with A.B. or his family.

"It was really surprising to me to see Premera impose this restriction," Hamburger said. "It was even more surprising because I know two other major insurers in town allow such treatment."

She pointed to policies under Kaiser Permanente and Regence BlueCross BlueShield, both attached to the complaint.

"I looked at all the policies I could find for basically the same treatment, but for cisgender people," Hamburger said. "And if you look at those policies that were attached to the complaint, they do not have an age limit."

Premera does cover other gender-affirming care for minors, including puberty blockers, hormone treatments and mental health care, the insurer said.

"Research on gender-affirming surgery for minors is continuing to develop," Lansford wrote. "As a learning organization, we want to listen and follow the science as it develops."

Because the lawsuit was filed as a class action, anyone with a Premera plan who requires gender-affirming care but was denied because of an age restriction could be eligible to join the complaint, Hamburger said. She and her team are searching for similar cases from the past four years, the period within the statute of limitations for ACA discrimination claims.

The complaint now awaits a response from Premera.

Meanwhile, A.B.'s surgery had been scheduled for this week. His attorneys declined to confirm whether or not the procedure happened, citing patient privacy.

"If we are allowing cisgender youth to obtain insurance coverage for medical procedures related to the conditions they have ... then there's this discriminatory standard that says trans youth can't possibly know who they are and they have to wait longer," Diskin said. "What that deprives trans youth, and by extension trans people, of is the dignity of using the health care and the health insurance that we pay for."

Sirianni Youtz Spoonemore Hamburger PLLC and Lambda Legal, which is also working on A.B.'s case, recently also sued Blue Cross Blue Shield of Illinois for excluding coverage for medically necessary gender-affirming care. Last December, a federal district judge ruled the insurance agency could not discriminate on the basis of sex in any of its operations, and could not administer gender-affirming care exclusions in its health plans.

In other parts of the country, bans on and legislation limiting health care for trans youth are multiplying, though court orders are slowing the process in some states. In Florida, a federal district judge issued a preliminary injunction earlier this month blocking the state's ban on gender-affirming care for youth.

In Oklahoma, the state attorney general's office agreed not to enforce a recent law that bans gender-affirming treatment for trans teens, pending resolution of a preliminary injunction.

"If Premera uses this hill to die on, we expect to litigate it to the hilt," Hamburger said. "But if you look at the cases around the country and how they're turning out, the science is winning."

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