Lack of guidance from the Medicare agency to doctors on how to bill for gender reassignment surgery has created access barriers for transgender beneficiaries who want to undergo the procedure, explains Bloomberg News.

It has been four years since Medicare started covering such services on a case-by-case basis, but doctors are still unsure of how to bill for these surgeries, and they run a risk of not being paid or having the cost burden placed on patients. Medicare doesn’t approve payment for the surgery until it has been performed.