Gender Affirmation Surgery

Policy ID: S-184-016

Section: Surgery

Effective Date: March 01, 2020

Revised Date: February 10, 2023

Revision Effective Date: May 01, 2023

Last Reviewed: March 23, 2023

Applies To: Commercial and Medicaid Expansion

Description

Gender affirmation surgery consists of medical and surgical treatments that change primary sex characteristics for individuals diagnosed with gender dysphoria. The treatment for gender dysphoria is for the individual to align their physical primary and/or secondary sex traits with their gender identity to the extent that alleviates the symptoms.

Criteria

Gender affirmation surgery may be considered medically necessary when ALL of the following are met:

The individual is greater than or equal to 18 years of age; and
The individual has the capacity to make a fully informed decision and to consent for treatment; and
The individual has been diagnosed with the gender dysphoria, including ALL of the following:
- The desire to live and be accepted as a member of another gender, usually accompanied by the wish to make their body as congruent as possible with the identified gender through surgery and hormone treatment; and
- The individual's transgender identity has been present persistently for at least six (6) months; and
- The dysphoria is not a symptom of a mental disorder; and
- Any significant medical or mental health diagnosis that is present including severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder) which may require psychotropic medications and/or psychotherapy, and include Substance Use Disorder must be reasonably well controlled before surgery is contemplated; and
- The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The individual is under the care of physicians and/or mental health providers who are able to document ALL of the following conditions:
- For chest surgery (mastectomy and chest reconstruction)
  - Initiation of hormonal therapy (unless medically contraindicated or individual is unable or unwilling to take hormones); and
  - One (1) referral from a qualified mental health professional with written documentation submitted to the physician performing the breast surgery; and
- For hysterectomy and salpingo-oopherectomy, orchiectomy:
  - Documentation of at least 12 months of continuous hormonal sex reassignment therapy, (unless medically contraindicated or individual is unable or unwilling to take hormones); and
- For vaginoplasty, phalloplasty, metoidioplasty:
  - The individual has successfully lived and worked within the identified gender role full-time for at least 12 months (real life experience) without returning to the original gender (unless doing so would jeopardize the individual's safety); and
  - Documentation of at least 12 months of continuous hormonal therapy, (unless medically contraindicated or individual is unable or unwilling to take hormones); and
  - Separate evaluation by the physician performing the genital surgery.; and
  - The individual must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for surgery. The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed.

Procedure Codes

55970

55980

When ALL of the above criteria are met, the following may be considered medically necessary:

Coverage is subject to the specific terms of the member's benefit plan:

Breast augmentation (including nipple/areolar reconstruction)
Chest masculinization (including nipple/areolar reconstruction)
Orchiectomy
Clitoroplasty
Colovaginoplasty
Labiaplasty
Orchiectomy
Penectomy
Vaginoplasty

Note: Although not a requirement, it is recommended that individuals undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

Breast reconstruction (e.g., mastectomy)
Colpectomy/Vaginectomy
Hysterectomy
Metoidioplasty
Penile prosthesis
Phalloplasty
Reduction mammoplasty
Salpingo-oophorectomy
Scrotoplasty
Testicular prosthesis implantation
Urethroplasty

Note: Penile prosthesis surgery is typically performed at stage two (2) or three (3) of a multi-stage phalloplasty (a minimum of nine (9) months following stage one (1)).

Surgical Revisions

Reconstructive surgery, following gender affirmation surgery may be considered medically necessary when it is performed for ANY of the following reasons:

Correct complications resulting from the initial surgery, or
Correct a medical condition that resulted from the initial surgery that requires intervention, or
Correct functional impairment resulting from initial surgery.

Reconstructive surgery following gender affirmation surgery to reverse natural signs of aging or if the individual is not satisfied with the aesthetic result is considered cosmetic and is not medically necessary.

Procedure Codes

19301

19303

19318

19325

19350

53410

53430

54120

54125

54400

54401

54405

54406

54408

54410

54411

54415

54416

54417

54520

54522

54530

54535

54660

54690

54592

55175

55180

55899

56620

56625

56805

57106

57107

57109

57110

57111

57291

57292

57335

58150

58200

58260

58262

58263

58267

58275

58285

58290

58291

58552

58554

58571

58573

58661

58720

58999

The following procedures that may be performed as a component of a gender affirmation surgery are considered cosmetic and, therefore, non-covered (this is not an all-inclusive list):

Blepharoplasty
Blepharoptosis
Chin augmentation
Collagen injections
Cricothyroid approximation
Facial bone reduction-facial feminizing
Hair removal – electrolysis or laser hair removal
Hair transplantation
Laryngoplasty
Lip reduction/enhancement
Liposuction
Mastopexy
Removal of redundant skin
Rhinoplasty
Rhytidectomy
Trachea shave/reduction thyroid chondroplasty

Procedure Codes

11920

11921

11922

11950

11951

11952

11954

15734

15771

15772

15773

15774

15775

15776

15820

15821

15822

15823

15824

15825

15826

15828

15829

15830

15832

15833

15834

15835

15836

15837

15838

15839

15876

15879

17340

17360

17380

17999

19316

21120

21121

21122

21123

21137

21138

21139

21172

21175

21179

21180

21181

21182

21183

21184

21188

21193

21194

21195

21196

21206

21208

21209

21244

21245

21246

21247

21255

21256

21270

21740

21742

21743

21899

30400

30410

30420

30430

30435

30450

30460

304562

30465

31580

31599

31899

40799

67900

67901

67902

67903

67904

67906

67908

67909

Q2026

Q2028

Preventive Medicine GRS

Please refer to the member specific benefit plan for screenings (e.g., mammogram, routine gynecological examination, pap smear).

Preventive services are subject to the terms of the member’s individual or group customer benefit.

Outpatient HCPCS (C Codes)

C1813

C2622

Diagnosis Codes

F64.0

F64.1

F64.2

F64.8

F64.9

Z87.890

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Removed deleted code

Internal Medical Policy Committee 1-19-2021 Removing procedure codes 19324 and 19350, Title change, revised criteria

Internal Medical Policy Committee 11-23-2021 Revision-updated clarifying language and coding effective January 01, 2022

Internal Medical Policy Committee 03-23-2022 Revision-statement " Coverage is subject to the specific terms of the member's benefit plan" added.

Internal Medical Policy Committee 07-21-2022 Revision

Added (including nipple / areolar reconstruction) after Breast augmentation and Chest masculinization and removed from noncovered section.

Internal Medical Policy Committee 3-23-2023 Coding update - Effective May 01, 2023

Added procedure codes 21137, 21138 and 21139.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-184-013

Section: Surgery

Effective Date: March 01, 2020

Revised Date: January 26, 2021

Revision Effective Date: March 01, 2021

Last Reviewed: January 19, 2021

Archived Date: December 31, 2021

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Gender affirmation surgery may be considered medically necessary when ALL of the following are met:

The individual is greater than or equal to 18 years of age; and
The individual has the capacity to make a fully informed decision and to consent for treatment; and
The individual has been diagnosed with the gender dysphoria, including ALL of the following:
- The desire to live and be accepted as a member of another gender, usually accompanied by the wish to make their body as congruent as possible with the preferred sex through surgery and hormone treatment; and
- The individual's transgender identity has been present persistently for at least six (6) months; and
- The dysphoria is not a symptom of another mental disorder; and
- The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The individual is under the care of physicians and/or mental health providers who are able to document ALL of the following conditions:
- For chest surgery (mastectomy and chest reconstruction)
  - Initiation of hormonal therapy (unless medically contraindicated or individual is unable or unwilling to take hormones); and
    - One referral from a qualified mental health professional with written documentation submitted to the physician performing the breast surgery; and
- For hysterectomy and salpingo-oopherectomy, orchiectomy:
  - Documentation of at least 12 months of continuous hormonal sex reassignment therapy, (unless medically contraindicated or individual is unable or unwilling to take hormones); and
- For vaginoplasty, phalloplasty, metoidioplasty:
  - The individual has successfully lived and worked within the desired gender role full-time for at least 12 months (real life experience) without returning to the original gender; and
  - Documentation of at least 12 months of continuous hormonal sex reassignment therapy, (unless medically contraindicated or individual is unable or unwilling to take hormones); and
  - Separate evaluation by the physician performing the genital surgery; and
  - The individual must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for. The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed.

Procedure Codes

55970

55980

When ALL of the above criteria are met, the following breast/genital surgeries may be considered medically necessary:

Feminization procedures:

Breast augmentation
Orchiectomy
Clitoroplasty
Colovaginoplasty
Labiaplasty
Orchiectomy
Penectomy
Vaginoplasty

Masculinization procedures:

Breast reconstruction (e.g., mastectomy)
Colpectomy/Vaginectomy
Hysterectomy
Metoidioplasty
Penile prosthesis
Phalloplasty
Reduction mammoplasty
Salpingo-oophorectomy
Scrotoplasty
Testicular prosthesis implantation
Urethroplasty

Note: Penile prosthesis surgery is typically performed at stage two (2) or three (3) of a multi-stage phalloplasty (a minimum of nine (9) months following stage one (1)).

Surgical Revisions

Reconstructive surgery, following gender affirmation surgery may be considered medically necessary when it is performed for ANY of the following reasons:

Correct complications resulting from the initial surgery, or
Correct a medical condition that resulted from the initial surgery that requires intervention, or
Correct functional impairment resulting from initial surgery.

Procedure Codes

19303

19318

19325

53430

54125

54400

54401

54405

54406

54408

54410

54411

54415

54416

54417

54520

54660

54690

55175

55180

55899

56805

57110

57291

57292

57335

58150

58262

58552

58554

58571

58573

58661

58999

The following procedures that may be performed as a component of a gender affirmation surgery are considered cosmetic and, therefore, non-covered (this is not an all-inclusive list):

Blepharoplasty
Blepharoptosis
Chin augmentation
Collagen injections
Cricothyroid approximation
Facial bone reduction-facial feminizing
Hair removal – electrolysis or laser hair removal
Hair transplantation
Laryngoplasty
Lip reduction/enhancement
Liposuction
Mastopexy
Removal of redundant skin
Rhinoplasty
Rhytidectomy
Trachea shave/reduction thyroid chondroplasty

Procedure Codes

11950

11951

11952

11954

15775

15776

15820

15821

15822

15823

15824

15825

15826

15828

15829

15830

15832

15833

15834

15835

15836

15837

15838

15839

15876

15879

17380

17999

19316

19350

21120

21121

21122

21123

21209

21225

21227

21899

30400

30410

30420

30430

30435

30450

31599

31899

40799

67900

67901

67902

67903

67904

67906

67908

67909

Preventive Medicine GRS

Please refer to the member specific benefit plan for screenings (e.g., mammogram, routine gynecological examination, pap smear).

Preventive services are subject to the terms of the member’s individual or group customer benefit.

Outpatient HCPCS (C Codes)

C1813

C2622

Diagnosis Codes

F64.0

F64.1

F64.2

F64.8

F64.9

Z87.890

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Removed deleted code

Internal Medical Policy Committee 1-19-2021 Removing procedure codes 19324 and 19350, Title change, revised criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policies Quick Search