## Facts

- Two transgender male minors enrolled in Arizona’s Medicaid program (AHCCCS) had diagnosed gender dysphoria and received AHCCCS-covered testosterone therapy.
- Treating providers recommended male chest reconstruction surgery to treat gender dysphoria.
- AHCCCS denied coverage based on a regulation excluding coverage for “gender reassignment surgeries.”
- Plaintiffs sued the AHCCCS Director in her official capacity and sought a mandatory preliminary injunction to enjoin the exclusion and require AHCCCS to cover the surgeries for them.
- The court held an evidentiary hearing with expert testimony; plaintiffs’ experts supported chest surgery as appropriate for some minors, while defense experts disputed necessity and safety for minors and emphasized less invasive care.

## Issues

1. Whether plaintiffs satisfied the heightened requirements for a mandatory preliminary injunction compelling AHCCCS to cover gender-affirming chest reconstruction surgery.
2. Whether plaintiffs clearly showed a likelihood of success on claims under the Medicaid Act, ACA § 1557, and the Equal Protection Clause challenging the categorical exclusion.
3. Whether plaintiffs clearly established irreparable harm absent immediate, court-ordered coverage for surgery.

## Decision

- The court denied the motion for a preliminary injunction.
- Plaintiffs did not clearly establish that chest reconstruction was medically necessary for these particular minors on the preliminary record.
- Plaintiffs did not clearly show a likelihood of success on the merits of their Medicaid Act, ACA § 1557, or Equal Protection claims.
- Plaintiffs did not meet the heightened showing required for mandatory relief that would alter the status quo and largely grant ultimate relief.

## Legal Principles

- A preliminary injunction requires showing likelihood of success, likely irreparable harm, balance of equities, and public interest.
- A mandatory preliminary injunction that compels affirmative action and changes the status quo is disfavored and requires a heightened showing that the facts and law clearly favor the moving party.
- When material expert evidence is conflicting and individualized medical necessity is not clearly established for the plaintiffs seeking relief, a court may deny mandatory preliminary injunctive relief.
- At the preliminary stage, uncertainty in the factual record can defeat a claim that federal statutes or equal protection principles clearly require the requested coverage.

## Conclusion

The court declined to order Arizona’s Medicaid program to cover gender-affirming chest reconstruction surgery at the preliminary stage, reasoning that the request sought mandatory, near-final relief and that the record did not clearly establish individualized medical necessity, irreparable harm warranting immediate relief, or a clear likelihood of success on the asserted statutory and constitutional theories.


Hennessy-Waller v. Snyder, 529 F. Supp. 3d 1031 (D. Ariz. 2021)