Coverage Policy Manual
Policy #: 2016024
Category: Surgery
Initiated: January 2017
Last Review: October 2018
  Gender Reassignment Surgery for Gender Dysphoria

Description:
For a person to be diagnosed with gender dysphoria, there must be a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. In children, the desire to be of the other gender must be present and verbalized. This condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
 
Gender dysphoria is manifested in a variety of ways, including strong desires to be treated as the other gender or to be rid of one’s sex characteristics, or a strong conviction that one has feelings and reac­tions typical of the other gender.*
 
Clinicians and researchers use the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (DSM-5™) to diagnose and classify mental disorders. The American Psychiatric Association (APA) approved DSM-5 in 2013, culminating a 14-year revision process. For more information, go to www.DSM5.org.
 
DSM-5 Criteria
In the U.S., the American Psychiatric Association (APA) permits a diagnosis of gender dysphoria if the diagnostic criteria in the DSM-5 are met. The criteria are:
 
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six month’s duration, as manifested by at least two of the following:
 
1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics); OR
 
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics; OR
 
3. A strong desire for the primary and/or secondary sex characteristics of the other gender; OR
 
4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender); OR
 
5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender); OR
 
6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender); AND
 
B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Policy/
Coverage:
EFFECTIVE JANUARY 2017
 
Coverage eligibility of Gender Reassignment Surgery for Gender Dysphoria ia a contract-specific benefit issue.
 
When benefits for gender reassignment surgery are available, coverage may vary and under some plans may be excluded.  For those plans providing benefits, prior authorization is required for any gender reassignment surgery.
 
When benefits are available, the following member criteria AND provider documentation criteria must be met:
 
Member Criteria:
1. The candidate is at least 18 years of age; AND
 
2. Has been diagnosed with gender dysphoria, including meeting all of the following indications:
a. The desire to live and be accepted as a member of the opposite sex (typically accompanied by the desire to make the physical body as congruent as possible with the identified sex through surgery and hormone treatment), AND
b. The new gender identity has been present for at least 24 months; AND
c. The gender identity disorder is not a symptom of another mental disorder or a chromosomal abnormality; AND
d. The gender identity disorder causes clinical distress or impairment in social, occupational, or other important areas of functioning, AND
 
3. For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is (Note: for those candidates requesting female to male surgery see item 4. below):
a. Recommended by a mental health professional AND
b. Provided under the supervision of a physician; and the supervising physician indicates that the patient has taken the hormones as directed, AND
 
4. For candidates requesting female to male surgery only:
a. When the initial requested surgery is solely a mastectomy, the treating physician may indicate that no hormonal treatment (as described in criteria 3. above) is required prior to performance of the mastectomy. In this case, the 12 month requirement for hormonal treatment will be waived only when all other criteria contained in this policy and in the member’s health benefit plan are met, AND
 
5. The candidate has completed a minimum of 12 months of successful continuous full time real-life experience in their new gender, with no returning to their original gender, OR
 
6. If the candidate does not meet the 12 month time frame criteria as noted in item 5. above, then the treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet these criteria. When submitted, the criteria in item 5. will be waived unless the criteria noted in item 5. above are specified as required in the candidate’s health benefit plan.
 
Provider Documentation Criteria:
At a minimum, at least two (2) treating clinicians must provide the following documentation. The documentation must be provided in letters from the appropriate clinicians and contain the information noted below:
 
1. The letters must attest to the psychological aspects of the candidate’s gender dysphoria.
a. One of the letters must be from a behavioral health professional with a doctoral degree (Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D) who is capable of adequately evaluating if the candidate has any co-morbid psychiatric conditions.
b. One of the letters must be from the candidate’s physician, who has treated the candidate for a minimum of 18 months (Note: if the candidate has not been treated continuously by one clinician for 18 months but has transferred care from one clinician to a second clinician, then both clinicians must submit documentation and their combined treatment must have been for 18 months). The letter or letters must document the following:
1. Whether the author of the letter is part of a gender identity disorder treatment team; and
2. The candidate’s general identifying characteristics; and
3. The initial and evolving gender, sexual, and other psychiatric diagnoses; and
4. The duration of their professional relationship including the type of psychotherapy or evaluation that the candidate underwent; and
5. The eligibility criteria that have been met by the candidate; and
6. The physician or mental health professional’s rationale for surgery; and
7. The degree to which the candidate has followed the treatment and experiential requirements to date and the likelihood of future compliance; and
8. The extent of participation in psychotherapy throughout the 12 month real-life trial, (if such therapy is recommended by a treating medical or behavioral health practitioner) and
9. That during the 12 month, real-life experience (for candidates not meeting the 12 month candidate criteria as noted in 5 and 6, the letter should still comment on the candidates ability to function and experience in the desired gender role), persons other than the treating therapist were aware of the candidate’s experience in the desired gender role and could attest to the candidate’s ability to function in the new role.
10. That the candidate has, intends to, or is in the process of acquiring a legal gender-identity-appropriate name change and
11. Demonstrable progress on the part of the candidate in consolidating the new gender identity, including improvements in the ability to handle:
• Work, family, and interpersonal issues
• Behavioral health issues, should they exist. This implies satisfactory control of issues such as
o Sociopathy
o Substance abuse
o Psychosis
o Suicidality
c. If the letters specified in 1a and 1b above come from the same clinician, then a letter from a second physician or behavioral health provider familiar with the candidate corroborating the information provided by the first clinician is required.
d. A letter of documentation must be received from the treating surgeon. If one of the previously described letters is from the treating surgeon then it must contain the documentation noted in the section below. All letters from a treating surgeon must confirm that:
1. The candidate meets the “candidate criteria” listed in this policy, AND
2. The treating surgeon feels that the candidate is likely to benefit from surgery, AND
3. The surgeon has personally communicated with the treating mental health provider or physician treating the candidate, AND that
4. The surgeon has personally communicated with the candidate and that the candidate understands the ramifications or surgery, including:
• The required length of hospitalizations,
• Possible complications of the surgery, and
• The post surgical rehabilitation requirements of the various surgical approaches and the planned surgery.
 
 
When benefits are available, the following gender reassignment surgeries---alone or in combination-- are covered:
 
Hysterectomy, salpingo-oophorectomy, ovariectomy,  orchiectomy, metoidioplasty, mastectomy or mammoplasty reduction (only for female-to-male gender transition), phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, or placement of testicular prostheses.
 
Transgender Surgery Exclusions:
The following procedures are considered cosmetic when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender reassignment surgery, including, but not limited to, the following:
        1. Abdominoplasty
        2. Blepharoplasty
        3. Breast augmentation
        4. Brow lift
        5. Calf implants
        6. Electrolysis
        7. Face lift
        8. Facial bone reconstruction
        9. Facial implants
        10. Gluteal augmentation
        11. Hair removal/hairplasty, when the criteria above have not been met
        12. Jaw reduction (jaw contouring)
        13. Lip reduction/enhancement
        14. Lipofilling/collagen injections
        15. Liposuction
        16. Nose implants
        17. Pectoral implants
        18. Rhinoplasty
        19. Thyroid cartilage reduction (chondroplasty)
        20. Voice modification surgery
        21. Voice therapy  
 
Other surgery exclusions include but are not limited to:
        1. Autologous tissue flap breast reconstructions
        2. Any services performed to reverse gender reassignment surgery.
        3. Gender reassignment surgical procedures not addressed as covered above and/or gender reassignment surgical procedures billed with codes not listed in this medical coverage policy.
 
 

Rationale:
Gender reassignment surgery presents significant medical and psychological risks, and the results are irreversible.  A step-wise approach to therapy for gender dysphoria, including accurate diagnosis and long-term treatment by a multidisciplinary team including behavioral, medical and surgical specialists, has been shown to provide the best results.  As with any treatment involving psychiatric disorders, a thorough behavioral analysis by a qualified practitioner is needed.  Once a diagnosis of gender dysphoria is established, treatment with hormone therapy and establishment of real-life transgender experience may be warranted.  Gender reassignment surgery should be considered only after such trials have been undertaken, evaluated and confirmed.  Hormone therapy, when indicated, should be administered under ongoing medical supervision and is important in beginning the gender transition process by altering body hair, breast size, skin appearance and texture, body fat distribution, and the size and function of sex organs. Hormone therapy is consistent with the development of secondary sexual characteristics vital to gender transition, and should be administered unless contraindicated.  Additionally, real-life experience living as the desired gender is important to validate the individual's desire and ability to incorporate into their desired gender role within their social network and daily environment.  This generally involves gender-specific appearance (garments, hairstyle, etc.), involvement in various activities in the desired gender role including work or academic settings, legal acquisition of a gender appropriate first name, and acknowledgement by others of their new gender role.  With regard real-life experience, to the 2012 WPATH document specifically states:
 
The criterion noted above for some types of genital surgeries – i.e., that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity – is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery. As noted in section VII, the social aspects of changing one's gender role are usually challenging – often more so than the physical aspects. Changing gender role can have profound personal and social consequences, and the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role. Support from a qualified mental health professional and from peers can be invaluable in ensuring a successful gender role adaptation (Bockting, 2008).
 
The duration of 12 months allows for a range of different life experiences and events that may occur throughout the year (e.g., family events, holidays, vacations, season-specific work or school experiences). During this time, patients should present consistently, on a day-to-day basis and across all settings of life, in their desired gender role. This includes coming out to partners, family, friends, and community members (e.g., at school, work, other settings).
 
Health professionals should clearly document a patient's experience in the gender role in the medical chart, including the start date of living full time for those who are preparing for genital surgery. In some situations, if needed, health professionals may request verification that this criterion has been fulfilled: They may communicate with individuals who have related to the patient in an identity-congruent gender role, or request documentation of a legal name and/or gender marker change, if applicable.
 
Once these treatment steps have been established, and have been stable for at least 12 months, an individual may be considered for gender reassignment surgery.
 
In many instances, the creation of a neovagina or a urethra for a neopenis requires an autologous skin graft from the forearm or thigh.  Such skin may be excessively hairy, which will impair the function of the newly constructed organ if not permanently removed.  Pre-operative permanent hair removal treatments to these areas may be warranted to prevent post-operative complications.
 
For both transmen and transwomen, additional surgeries have been proposed to improve the gender appropriate appearance of the individual.  Procedures such as breast augmentation, liposuction, Adam's apple reduction, rhinoplasty, facial reconstruction, and others have no medically necessary role in gender identification and are considered cosmetic in nature.
 
There is insufficient evidence to prove the efficacy of gender reassignment surgery for specific subgroups of persons selected for such intervention. The subgroups of transsexual people who will most likely benefit from sex reassignment surgery are not clearly identifiable from the published evidence. The evidence is based on a small number of studies with weak study designs and significant methodological limitations.

CPT/HCPCS:
17380Electrolysis epilation, each 30 minutes
17999Unlisted procedure, skin, mucous membrane and subcutaneous tissue
19300Mastectomy for gynecomastia
19303Mastectomy, simple, complete
19304Mastectomy, subcutaneous
19318Reduction mammaplasty
19350Nipple/areola reconstruction
54125Amputation of penis; complete
54520Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach
54660Insertion of testicular prosthesis (separate procedure)
54690Laparoscopy, surgical; orchiectomy
55180Scrotoplasty; complicated
55970Intersex surgery; male to female
55980Intersex surgery; female to male
56625Vulvectomy simple; complete
56800Plastic repair of introitus
56805Clitoroplasty for intersex state
57110Vaginectomy, complete removal of vaginal wall;
57291Construction of artificial vagina; without graft
57292Construction of artificial vagina; with graft
57295Revision (including removal) of prosthetic vaginal graft; vaginal approach
57296Revision (including removal) of prosthetic vaginal graft; open abdominal approach
57426Revision (including removal) of prosthetic vaginal graft, laparoscopic approach
58150Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);
58552Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58554Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58571Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58573Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

References: American College of Obstetricians and Gynecologists (ACOG).(2011) Healthcare for transgender individuals. Committee Opinion. No 512. December 2011. Obstet Gynecol 2011; 118:1454-8.

American Psychiatric Association (APA).(2013) Gender dysphoria. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5™). Arlington, VA: American Psychiatric Publishing; 2013: 451-459.

Day P.(2015) Trans-gender reassignment surgery. New Zealand health technology assessment (NZHTA). The clearing house for health outcomes and Health technology assessment. February 2002; Volume 1 Number 1 Available at: http://nzhta.chmeds.ac.nz/publications/trans_gender.pdf. Accessed on December 24, 2015.

The World Professional Association for Transgender Health; Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People; 7th Version; July 2012. Accessed athttp://www.wpath.org/uploaded_files/140/files/IJT%20SOC,%20V7.pdf on 10/02/2013.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2019 American Medical Association.