States violate the Constitution’s guarantee of equal protection under the law when their health insurance programs cover surgical procedures such as breast augmentation or reduction except when performed as treatment for a gender dysphoria diagnosis, a sharply divided federal appeals court ruled Monday.

In its 8-6 decision, the U.S. Court of Appeals for the Fourth Circuit affrimed lower court ruling  striking down West Virginia and North Carolina’s disparate treatment of cis and transgender individuals when they seek these same procedures.