Allison Escolastico, a 30-year-old transgender woman, has wanted breast augmentation surgery for a decade. By 2019, she finally thought her insurance company, Aetna, would pay for it, only to find that it considered the procedure cosmetic, not medically necessary, and refused to cover it. “I knew from my case, it wasn’t cosmetic,” said Escolastico, who contacted a lawyer after she lost her appeal last year. “I knew I had to fight for this,” she said. Escolastico’s surgery is scheduled for February. Working with the Transgender Legal Defense and Education Fund, a nonprofit that advocates transgender rights, and Cohen Milstein Sellers and Toll, a large law firm that represents plaintiffs, she and a small group of trans women persuaded Aetna to cover the procedure if they could show it to be medically necessary. To qualify, the women would need to demonstrate that they had persistent gender dysphoria, undergo a year of feminizing hormone therapy and have a referral from a mental health professional. The shift by Aetna represents an important evolution in how health insurers view the medical needs of transgender individuals. While some insurers offer a broad range of surgeries for trans women if they are deemed medically necessary, others exclude breast augmentation and other treatments as merely cosmetic.