Description

Gender reassignment surgery (GRS), either as a male-to-female (MTF) transition or as a female-to-male (FTM) transition, consists of medical and surgical treatments that change primary sex characteristics for individuals with gender dysphoria or gender identity disorder who wish to make a permanent transition.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Criteria

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

GRS 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 of transsexualism, including ALL of the following:
  • The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
  • The individual’s transsexual identity has been present persistently for at least two (2) years; and
  • The disorder is not a symptom of another mental disorder or a chromosomal abnormality; and
  • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The individual is an active participant in a recognized gender identity treatment program and demonstrates ALL of the following conditions:
  • 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
  • For breast surgery
    • 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 genital surgery
    • Documentation of at least 12 months of continuous hormonal sex reassignment therapy, (unless medically contraindicated or indivudal is unable or unwilling to take hormones) (may be simultaneous with real life experience);
    • Two referrals from qualified mental health professionals who have independently assessed the individual. If the first referral is from the individual’s psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (e.g., if practicing within the same clinic) may be sent*; and
  • Separate evaluation by the physician performing the genital surgery.

* At least one (1) letter must be a comprehensive report.

Procedure Codes

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

MTF:

• Breast augmentation
• Orchiectomy
• Clitoroplasty
• Colovaginoplasty
• Labiaplasty
• Orchiectomy
• Penectomy
• Vaginoplasty

Note: Although not a requirement, it is recommended that MTF 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.

FTM:

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

Procedure Codes

The following procedures that may be performed as a component of a gender reassignment 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 €" electrolysisor laser hair removal
• Hair transplantation
• Laryngoplasty
• Lip reduction/enhancement
• Liposuction
• Mastopexy
• Nipple/areola reconstruction
• Removal of redundant skin
• Rhinoplasty
• Rhytidectomy
• Trachea shave/reduction thyroid chondroplasty

Procedure Codes

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)

Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

A network provider can bill the member for the cosmetic service.

A network provider cannot bill the member for the non-covered service.

Links

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1. Levey R, Dunayevich E. Gender dysphoria. Medscape. 2013.

2. Gooren L, Snyder P, Martin, K, et al. Transsexualism: Epidemiology, pathophysiology, and diagnosis. UpToDate. 2013.

3. Heino R, Sumia M, Tyolajarvi M, et al. Two years of gender identity service for minors: Overrepresentation of natal girls with severe problems in adolescent development. Child Adolesc Psychiatry Ment Health. 2015;9:9.

4. Bockting W, Miner M, Romine R, et al. Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health. 2013;103(5):943–951.

5. Hess J, Neto RR, Panic L, et al. Satisfaction with male-to-female gender reassignment surgery.Dtsch Arztebl Int. 2014;111(47):795–801.

6. Garcia M, Nim C, De Luca F, et al. Overall satisfaction, sexual function, and the durability of neophallus dimensions following staged female to male genital gender confirming surgery: The Institute of Urology, London U.K. experience. Transl Androl Urol. 2014;3(2):156-162.

7. Bartolucci C, Gil E, Salamero M, et al. Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery. J Sex Med. 2015;12:180–188.

8. American Psychiatric Association. Gender dysphoria – DSM5. 2013.

9. Center of excellence for transgender health, department of family and community medicine, university of California San Francisco. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people; 2nd edition. Deutsch MB, ed. 2016.

10. TransHealth-2013.