Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2015 Title: FEHBP Gender Reassingment Surgery
Revision Date: 01/01/2020 Document: BI486:00
CPT Code(s): 19303, 19304, 53430, 54125, 54520, 54690, 55970, 55980, 56625, 56800, 56805, 57110, 57291, 57292, 57335, 58150, 58262, 58291, 58552, 58554, 58571, 58573, 58661, 58999
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

 

1.     This policy is specific to the Federal Employees Health Benefits.

2.     Gender reassignment surgical procedures require preauthorization.  In order for coverage to be authorized, ALL of the following criteria must be met:

a.     The member is 18 years of age or older

b.     The member has a definitive diagnosis of persistent gender dysphoria that has been made and documented by a qualified mental health professional.

c.     The member has received continuous hormone therapy for 12 months or more under the supervision of a physician.

d.     The member has lived as their reassigned gender full-time for 12 months or more.

e.     At least two different mental health professionals, not working in the same group or otherwise associated with each other, have evaluated the member and recommended gender reassignment surgery as medically necessary.  At least one of the mental health professionals must be a psychiatrist or clinical (PhD) psychologist.

The member’s medical and mental health providers document that there are no contraindications to the planned surgery and agree with the plan, within three months of the prior authorization request.

 

Medical Statement

1.    Gender reassignment surgical procedures require preauthorization.  In order for coverage to be authorized, ALL of the following criteria must be met:

a.    The member is 18 years of age or older

b.    The member has a definitive diagnosis of persistent gender dysphoria that has been made and documented by a qualified mental health professional.

c.    Recommendation for sex reassignment surgery by two qualified mental health professionals, at least one of whom is either a psychiatrist or a PhD clinical psychologist with experience treating gender dysphoria.

d.    The member has received continuous hormone therapy for 12 months or more under the supervision of a physician.

a.    The member has lived as their reassigned gender full-time for 12 months or more.

b.    At least two different mental health professionals, not working in the same group or otherwise associated with each other, have evaluated the member and recommended gender reassignment surgery as medically necessary.  At least one of the mental health professionals must be a psychiatrist or clinical (PhD) psychologist.

e.    The member’s medical and mental health providers document that there are no contraindications to the planned surgery and agree with the plan, within three months of the prior authorization request.

2.    For male-to-female procedures, the following surgeries may be authorized:  penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty, vulvoplasty, mammoplasty, prostatectomy, urethroplasty

3.    For female-to-male procedures, the following surgeries may be authorized:  mastectomy, hysterectomy, salpingectomy, oophorectomy, vaginectomy, vulvectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, testicular prosthesis implantation.

4.    QualChoice does not cover reversal of any of the above procedures.

5.    The following procedures are not considered necessary to gender reassignment, and so are considered cosmetic (not an all-inclusive list): facial bone reduction, blepharoplasty, rhinoplasty, rhtidectomy, osteoplasty, genioplasty, forehead augmentation, penile prosthetic implantation, reduction thyroid chondroplasty, and any other procedures designed to alter appearance.

6.    Procurement, cryopreservation, and storage of sperm, oocytes, or embryos are not considered medically necessary and are not covered.

Codes Used In This BI:

19303             Mastectomy, simple, complete

19304             Mastectomy, subcutaneous Deleted code eff 01/01/2020

53430             Urethroplasty, reconstruction of female urethra

54125             Amputation of penis; complete

54520             Orchiectomy, simple (including subcapsular), w/ or w/out testicular prosthesis, scrotal or inguinal approach

54690             Laparoscopy, surgical; orchiectomy

55970             Intersex surgery; male to female

55980             Intersex surgery; female to male

56625             Vulvectomy simple; complete

56800             Plastic repair of introitus

56805             Clitoroplasty for intersex state

57110             Vaginectomy, complete removal of vaginal wall

57291             Construction of artificial vagina; w/out graft

57292             Construction of artificial vagina; w/graft

57335             Vaginoplasty for intersex state

58150             Total abdominal hysterectomy (corpus and cervix), w/ or w/out removal of ovary(s)

58262             Vaginal hysterectomy, for uterus 250 g or less; w/removal of tube(s), and/or ovary(s)

58291             Vaginal hysterectomy, for uterus greater than 250 g; w/removal of tube(s), and/or ovary(s)

58552             Laparoscopy, surgical, w/vaginal hysterectomy, for uterus 250 g or less; w/removal of tube(s) and/or ovary(s)

58554             Laparoscopy, surgical, w/vaginal hysterectomy, for uterus greater than 250 g; w/removal of tube(s) and/or ovary(s)

58571             Laparoscopy, surgical, w/total hysterectomy, for uterus 250 g or less; w/removal of tube(s) and/or ovary(s)

58573             Laparoscopy, surgical, w/total hysterectomy, for uterus greater than 250 g; w/removal of tube(s) and/or ovary(s)

58661             Laparoscopy, surgical; w/removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)

58999             Unlisted procedure, female genital system (nonobstetrical)


Background

Gender reassignment surgery, also called sexual reassignment surgery, encompasses those procedures that are intended to reshape a male body into a body with female appearance, or vice versa.  Gender reassignment surgery is part of a treatment plan for gender dysphoria.

 

Gender dysphoria is defined as discomfort or distress that is caused by a discrepancy between a person’s gender identity and the person’s assigned sex at birth, including the associated gender role and/or primary and secondary sex characteristics. 

 

Gender reassignment surgery is intended to be a permanent change, establishing congruency between an individual’s gender identity and physical appearance, and is not easily reversible.  A careful and accurate diagnosis is essential for treatment and can only be made with a long-term diagnostic process.  A patient’s self-assessment and desire for sex reassignment cannot be considered reliable indicators of gender dysphoria, or adequate predictors of success in treatment.

 

Prior to gender reassignment surgery, patients generally undergo prolonged hormone therapy.  Lifelong maintenance is usually required, even after surgery.  Prior to undergoing irreversible surgery, the individual is also expected to undergo what is referred to as “real life experience,” in which s/he adopts the new or evolving gender role and lives in that role continuously as part of the transition.  This process assists in confirming the person’s desire for gender role change, ability to function in this role long-term, and the adequacy of her/his support system.  During this time, the individual would be expected to maintain the functional lifestyle, participate in community activities, and provide an indication that others are aware of the change in gender role.


Reference

Addendum:

Effective 09/01/2017: Diagnosis code correction throughout policy.  Updated F64.1 to F64.0.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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