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.
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:
* At least one (1) letter must be a comprehensive report.
When ALL of the above criteria are met, the following breast/genital surgeries may be considered medically necessary for the following indications:
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.
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)).
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):
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
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.
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Gooren L, Snyder P, Martin, K, et al. Transsexualism: Epidemiology, pathophysiology, and diagnosis. UpToDate. 2013.
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.
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.
Hess J, Neto RR, Panic L, et al. Satisfaction with male-to-female gender reassignment surgery.Dtsch Arztebl Int. 2014;111(47):795–801.
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.
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.
American Psychiatric Association. Gender dysphoria – DSM5. 2013.
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.