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)