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A Medical Necessity

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A Medical Necessity

Ministry of Health and Long-Term Care

Date: 2007

The Ombudsman received a complaint from a social worker at an Ontario children’s hospital about the impact of a decision to stop funding the prosthesis insertion procedure for boys under the age of 18 who had lost testicles due to disease or other conditions. The social worker complained on behalf of a group of caregivers at the hospital, including doctors and nurses.

The procedure had been dropped from OHIP’s schedule of publicly funded benefits in 1998, but the hospital had continued to cover the cost out of its own budget until August 2005. The cost of the surgery, at $2,300 per testicle, proved to be a hardship for many families, who were also reluctant to seek assistance because they did not want to draw attention to the boys’ condition.

On April 27, 2006, the Ombudsman notified the Ministry of Health and Long-Term Care of his intention to investigate this systemic issue. SORT investigators interviewed Ministry officials and their counterparts in other provinces, doctors and health professionals from two children’s hospitals, and affected teens and their families. The doctors unanimously agreed that testicular prostheses were medically necessary for psychological reasons and patient self-esteem. Several likened the psychological issues faced by the young men to the experiences of women who have had mastectomies.

On May 15, 2006, the Minister of Health and Long-Term Care, George Smitherman, announced that coverage for testicular prosthesis surgery would be restored for boys under 18 in cases where it was deemed medically necessary. In a letter dated June 7, 2006, the Deputy Minister of Health confirmed to the Ombudsman that the Ministry would seek the necessary approvals to relist the procedure as insured under OHIP.

Following Cabinet approval, a bulletin was posted to the Ministry’s website on Jan. 11, 2007, which announced that coverage for this procedure had been restored, retroactive to May 12, 2006.

-From Annual Report 2006-2007