Hennessy-Waller v. Snyder

D.H. and John Doe (plaintiffs) were minors enrolled in the Arizona Health Care Cost Containment System (AHCCCS) (defendant), Arizona’s Medicaid program. Both D.H. and Doe were transgender and were undergoing hormone therapy to treat gender dysphoria, which was covered by AHCCCS. D.H. and Doe, on the recommendation of their doctors, requested male chest reconstruction surgery, a type of gender-affirming surgery, to further treat their gender dysphoria. AHCCCS denied coverage, stating that AHCCCS did not cover gender-reassignment surgeries (the challenged exclusion). D.H. and Doe sued AHCCCS and sought a preliminary injunction barring enforcement of the challenged exclusion, arguing that the challenged exclusion violated the Medicaid Act, the Affordable Care Act (ACA), and the Equal Protection Clause because (1) the challenged exception denied D.H. and Doe medically necessary treatment because they were transgender, which was equivalent to sex-based discrimination, and (2) AHCCCS covered chest reconstruction surgery to treat other diagnoses with comparable need, such as breast cancer. AHCCCS challenged, arguing that (a) the chest reconstruction surgery was not medically necessary, (b) D.H.’s and Doe’s needs for the surgery were not on par with those of others who received the surgery to treat different diagnoses, and (c) the challenged exclusion was not discriminatory because it treated all transgender individuals equally and because the exclusion denied coverage for only gender-affirming surgeries, not hormone therapies. At a hearing, D.H. and Doe and AHCCCS each presented conflicting medical expert testimony regarding the safety and medical necessity of male chest reconstruction surgery as a treatment for gender dysphoria in minors. Because D.H. and Doe’s experts had never physically examined either D.H. or Doe, their experts could not state whether the surgery was medically necessary for D.H. and Doe specifically.