The 4th U.S. Circuit Court of Appeals issued a ruling on Monday requiring state health insurance plans to pay for gender transition surgeries, a decision that comes amid a nationwide struggle over transgender healthcare policy.

The ruling came in a set of cases in West Virginia and North Carolina, in which state officials justified not covering the surgeries, including double mastectomies and vaginoplasties, on the basis of cost rather than on considerations related to gender identity and expression.

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In the majority opinion, Judge Roger Gregory called the restrictions “obviously discriminatory” based on both sex and gender.

This is a developing story.