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