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.

Criteria

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, 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 transgender identity has been present persistently for at least two (2) years; and
  • The dysphoria 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 individual is unable or unwilling to take hormones)(may be simultaneous with real life experience); and
    • 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
• 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)).

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)

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

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

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.