DES MOINES, Iowa (AP) — Iowa cannot deny two transgender women Medicaid coverage for sex reassignment surgery, a state court judge ruled Thursday, declaring a policy denying their care violates the Iowa Constitution and its civil rights law.

Carol Ann Beal of northwest Iowa and EerieAnna Good of the Quad Cities in eastern Iowa filed the lawsuit last year after their Medicaid provider and the Iowa Department of Human Services denied surgery requests recommended by doctors.

Judge Arthur Gamble said in his ruling that the state agency is obligated to ensure that its regulations conform to laws including the Iowa Civil Rights Act and the Iowa Constitution which trump any prior regulations created by administrative rule.

Gamble said the language of the Iowa regulation was adopted in 1995 for the purpose of denying coverage for sex reassignment surgery after federal appellate court rulings that such procedures should be covered.

"This decision was made without regard to the law and facts," he said. "The agency acted in the face of evidence upon which there is no room for difference of opinion among reasonable minds."

Good, 27, and Beal, 42, were born male but have identified as female since childhood and applied to have surgery to their medical providers under the state's Medicaid program, which provides care for the poor and disabled. They were denied by the providers, appealed to the state agency, which oversees the program, and were again denied.

They sued in September 2017 arguing that medical consensus holds that gender dysphoria — feeling an identity opposite to one's biological sex — is not only a psychological disorder but has a strong biological component and evolves as a result of the interaction of developing brain and sex hormones.

They said sex reassignment surgery is not cosmetic but is meant to prevent social dysfunction, physical pain, and even death due to suicide.

Gamble said the medical providers for the women offered no dispute of the medical claims in court and the agency denied their requests citing its regulation denying such coverage.

Eighteen states have adopted formal policies banning discrimination in transgender transition-related care and insurance coverage, according to the National Center for Transgender Equality, a Washington-based social justice advocacy organization.

Although the Iowa agency has 30 days to appeal to the Iowa Supreme Court, Gamble's ruling allows the women to proceed with seeking Medicaid coverage for surgeries without further delay, said Rita Bettis, legal director for the Civil Liberties Union of Iowa, which represented the women in the lawsuit.

An Iowa attorney general's office spokesman says no decision has been made on an appeal.

"DHS will not be commenting," the agency's spokesman replied by email.

"Today is a historic day for civil rights in Iowa," Bettis said. "This is the first court decision under the Iowa Civil Rights Act finding that this type of discrimination violates the state civil rights act protections against discrimination on the basis of gender identity."

Keenan Crow, director of policy and advocacy for One Iowa, a statewide organization for LGBTQ — lesbian, gay, bisexual, transgender and queer/questioning — said his group has seen first-hand how "powerful, lifesaving and essential this kind of care can be to transgender Iowans."

The decision will quite literally save lives, he said.