Effective Date:

a)    This policy will apply to all services performed on or after the above 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.

The diagnosis and individualized treatment of Gender Dysphoria (the broad umbrella encompassing all gender identity disorders) is covered per the guidelines described in this policy. Cross-sex hormone therapy or gender reassignment surgery may be considered on a case by case basis, if determined to be medically necessary and all criteria have been met.  All cross-sex hormone therapy or gender reassignment surgeries require prior-authorization.

Please Note:

QualChoice reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in this policy. Services that are provided outside of following guidelines may not meet coverage criteria and may lead to recoupment of payment.

It is better and often less costly to get care from doctors who are in QualChoice network. If the member gets care from an out-of-network Health care provider, even if care is given at a network doctor’s office or facility, the member’s cost may be higher.

Cross-sex Hormone Therapy – Requires prior-authorization (6 month intervals)

Before initiation of cross-sex hormone therapy, the following gender identity related diagnoses need to be confirmed by a psychiatrist: F64.0 (Transsexualism), F64.2 (Gender identity disorder of childhood), F64.8 (Other gender identity disorders), and F64.9 (Gender Identity disorder, unspecified). The only gender identity disorder diagnosis not requiring confirmation by a psychiatrist is Z87.890 (Personal history of sex reassignment).  In some instances cross-sex hormone therapy has already been initiated without a confirmed diagnosis of GD—either by a previous prescribing physician or by the patient obtaining hormones illicitly via the internet or other sources.  It is the responsibility of the prescribing physician (whether initiating or continuing previously initiated therapy) to ensure there is a confirmed diagnosis of GD.  A psychosocial assessment should be conducted and informed consent needs to be obtained by the prescribing physician.  

The criteria for cross sex hormone therapy are as follows:

-       Persistent (> 1 year), well-documented gender dysphoria (with confirmation of diagnosis by a psychiatrist),

-       Capacity to make a fully informed decision and to consent for treatment;

-       Member must be at least 18 years of age;

-       If significant medical or mental health concerns are present, they must be reasonably well controlled.

The presence of co-existing mental health diagnoses or medical comorbidities does not necessarily preclude access to cross-sex hormones. However, these concerns should be managed and stabilized prior to treatment of gender dysphoria.

Cross-sex hormonal interventions are not without risk for complications, including (in some instances) irreversible physical changes. Medical records should indicate that an extensive evaluation was completed to explore psychological, family, and social issues both before and after treatment. Prescribing providers should also document that all information has been provided and understood regarding all aspects associated with the use of cross-sex hormone therapy, including both benefits and risks.  In order to minimize risks of cross-sex hormone therapy, blood tests should be used to monitor hormone levels. 

Continued authorization (beyond 6 months) of cross-sex hormone therapy is contingent on providing the results of blood test hormone levels.  It is the responsibility of prescribers to avoid supraphysiologic hormone levels (for the desired gender) and to not rely exclusively on patient requests to determine hormone dosing.  Hormone doses should be reduced if supraphysiologic levels (for the desired gender) are detected.  Not staying within the physiologic range (for the desired gender) increases the risk of harm to the patient and liability for the prescribing physician.

Gender Reassignment Surgery – Requires prior-authorization

Readiness criteria for gender reassignment surgery include the individual demonstrating progress in consolidating gender identity, and demonstrating progress in dealing with work, family, and interpersonal issues resulting in an improved state of mental health. In order to check the eligibility and readiness criteria for gender reassignment surgery, it is important for the individual to discuss the matter with a professional provider who is well-versed in the relevant medical and psychological aspects of GD. The mental health and medical professional providers responsible for the individual`s treatment should work together in making a decision about the use of cross-sex hormones during the months before the gender reassignment surgery. Transsexual individuals should regularly participate in psychotherapy in order to have smooth transitions and adjustments to the new social and physical outcomes.

Services that are considered cosmetic for men or women without gender dysphoria (who are unsatisfied with their naturally endowed secondary sexual characteristics) are also considered cosmetic for the treatment of gender dysphoria and are therefore not covered. This is not an all-inclusive list:

·         Blepharoplasty – Removal of redundant skin of upper and/or lower eyelids and protruding periorbital fat

·         Chin augmentation – Reshaping or enhancing the size of the chin

·         Collagen injections

·         Cricothyroid approximation – Voice modification that raises the vocal pitch by simulating contractions of the cricothyroid muscle with sutures

·         Facial feminizing (e.g., facial bone reduction)

·         Hair removal / hair transplantation

·         Laryngoplasty – Reshaping of laryngeal framework (voice modification surgery)

·         Lip Reduction / Enhancement – Decreasing / enlarging lip size

·         Liposuction – Removal of fat

·         Mammaplasty – Breast augmentation

·         Mastopexy – Breast lift

·         Rhinoplasty – Reshaping of nose

·         Rhytidectomy – Face lift

·         Trachea shave/reduction thyroid chondroplasty – Reduction of the thyroid cartilage

Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member.

Gender reassignment surgery must be preauthorized and determinations are made on a case by case basis. Surgical treatment for transsexualism (F64.0) may be eligible for reimbursement when medical necessity and documentation requirements outlined within this policy are met.

Surgical treatment for gender dysphoria may be considered medically necessary when ALL of the following criteria are met:

·      The individual is at least 18 years of age.

·       A gender reassignment treatment plan is created specific to an individual beneficiary

·       The individual has a documented Diagnostic and Statistical Manual of Mental Disorders -Fifth Edition, DSM-5 ™ diagnosis of GD—confirmed by a psychiatrist:

A.  A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months 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.

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.

3.    A strong desire for the primary and/or secondary sex characteristics of the other gender.

4.    A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).

5.    A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender). 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).

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

1.    One letter from a mental health professional that has had, at minimum, twelve months of psychotherapy therapy sessions attesting to all of the following clinical criteria:

(i)    That any co-morbid psychiatric or other medical conditions are stable and that the individual is prepared to undergo surgery.

(ii)  That the patient has had persistent and chronic gender dysphoria.

(iii) That the patient has completed twelve months of continuous, full-time, real-life experience (i.e., the act of fully adopting a new or evolving gender role or gender presentation in everyday life) in the desired gender.

(iv) The individual, if required by the mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider.

(v)  Unless medically contraindicated (or the individual is otherwise unable to take

cross-sex hormones), there is documentation that the individual has participated in twelve consecutive months of cross-sex hormone therapy of the desired gender continuously and responsibly (e.g., screenings and follow-ups with the professional provider).

(vi) The individual has knowledge of all practical aspects (e.g., required lengths of hospitalizations, likely complications, and post-surgical rehabilitation) of the gender reassignment surgery.

Codes Used In This BI:

19301       Mastectomy, partial;

19303       Mastectomy, simple, complete

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

53410       Urethroplasty, 1-stage reconstruction of male anterior urethra

53430       Urethroplasty, reconstruction of female urethra

54125       Amputation of penis, complete 

54520       Orchiectomy, simple, w/or w/out testicular prosthesis, scrotal or inguinal

       approach

54660       Insertion of testicular prosthesis

54690       Orchiectomy, laparoscopy, surgical

55175       Scrotoplasty; simple

55180       Scrotoplasty; complicated

55899       Unlisted procedure, male genital system

55970       Intersex surgery; male to female [a series of staged procedures that includes

                 Male genitalia; removal, penile dissection, urethral transposition, creation of

                 Vagina and labia with stent placement]

55980       Intersex surgery; female to male [a series of staged procedures that include

                 Penis and

                 Scrotum formation by graft, and prostheses placement]

56625       Vulvectomy simple; complete

56805       Clitoroplasty for intersex state

57106       Vaginectomy, partial removal of vaginal wall;

57107       w/ removal of paravaginal tissue (radical Vaginectomy)    

57110       Vaginectomy, complete removal of vaginal wall;

57111       w/ removal of paravaginal tissue (radical Vaginectomy)   

57335       Vaginoplasty for intersex state

58150       Total abdominal hysterectomy, w/ or w/out rmvl of tube(s), w/ or w/out rmvl of

                 ovary(s)

58180       Supracervical abdominal hysterectomy, w/ or w/out rmvl of tube(s), w/ or

                 w/out rmvl of ovary(s)

58260       Vaginal hysterectomy, for uterus 250 g or less

58262       w/ removal of tube(s) and/or ovary(s)

58275       Vaginal hysterectomy, w/ total or partial Vaginectomy;

58280       w/ repair of enterocele

58285       Vaginal hysterectomy, radical

58290       Vaginal hysterectomy, for uterus greater than 250 g;

58291       w/ removal of tube(s) and/or ovary(s)

58541       Laparoscopy, surgical, Supracervical hysterectomy, for uterus 250 g or less;

58542       w/ removal of tube(s) and/or ovary(s)

58543       Laparoscopy, surgical, Supracervical hysterectomy, for uterus greater than

                 250g;

58544       w/ removal of tube(s) and/or ovary(s)

58550       Laparoscopy, surgical, w/ vaginal hysterectomy, for uterus 250 g or less;

58552       w/ removal of tube(s) and/or ovary(s)

58553       Laparoscopy, surgical, w/ vaginal hysterectomy, for uterus greater than 250g;

58554       w/ removal of tube(s) and/or ovary(s)

58570       Laparoscopy, surgical, w/ total hysterectomy, for uterus 250 g or less;

58571       w/ removal of tube(s) and/or ovary(s)

58572       Laparoscopy, surgical, w/ total hysterectomy, for uterus greater than 250 g;

58573       w/ removal of tube(s) and/or ovary(s)

58661       Laparoscopy, surgical, w/ rmvl of adnexal structures (prtl or ttl oophorectomy

                 and/or Salpingectomy

58720       Salpingo-oophorectomy, complete or partial, unilateral or bilateral

58999       Unlisted procedure, female genital system, non-obstetrical (i.e. metoidioplasty with initial phalloplasty)

J1000       Injection, depo-estradiol cypionate, up to 5 mg
J1071       Injection, testosterone cypionate, 1 mg

J1380       Injection, estradiol valerate, up to 10 mg
J1410       Injection, estrogen conjugated, per 25 mg
J1435       Injection, estrogen, per 1 mg

J3121       Injection, testosterone enanthate, 1 mg

J3145       Injection, testosterone undecanoate, 1 mg

Gender Dysphoria (GD) is defined by the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, DSM-5 ™ as a condition characterized by the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender also known as “natal gender”, which is the individual’s sex determined at birth. Individuals with gender dysphoria experience confusion in their biological gender during their childhood, adolescence, or adulthood. These individuals demonstrate clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The broad umbrella of GD encompasses a variety of gender identity disorders characterized by the desire to be regarded by others as a member of the other sex. Individuals with GD may develop social isolation, emotional distress, poor self-image, depression, and anxiety. The diagnosis of GD is not made if the individual has a congruent physical intersex condition such as congenital adrenal hyperplasia.

Individualized Therapy

While many mental health professionals or other specialties may recognize symptoms of GD, a licensed psychiatrist should confirm the diagnosis before initiating therapy.  The degree of GD is highly variable and the interventions needed to manage GD must be individualized based on where the patient falls in the GD continuum (and the specific gender identity disorder under the broader umbrella of gender dysphoria).  Many patients respond to less aggressive interventions such as psychotherapy with or without medical/hormonal management. As with any non-emergent condition, it is clinically prudent to first try interventions that are associated with less risk and do not have irreversible consequences.  This is consistent with dictum to “first do no harm.” If an adequate trial of less aggressive interventions has proven inadequate then more aggressive interventions can be justified and potential complications can be more easily defended.  The most aggressive, risky intervention is gender reassignment surgery for male-to-female transsexuals (transwomen) or female-to-male transsexuals (transmen).

Initially, the individual may go through the real-life experience in the desired role, followed by (if needed) cross-sex hormone therapy.  If prior steps have been insufficient then gender reassignment surgery to change the genitalia and other sex characteristics can be considered. Although cross-sex hormone therapy may (in some instances) cause irreversible changes, gender reassignment surgery (by definition) is always considered an irreversible physical intervention.

Gender reassignment surgical procedures are not without risk for complications; therefore, individuals should undergo an extensive evaluation to explore psychological, family, and social issues both pre and postoperatively.

Some surgeries may improve stereotypical gender-appropriate appearance (even in individuals without a diagnosis of GD) but provide no significant improvement in physiological function. These surgeries are considered cosmetic and are non-covered—with or without a diagnosis of GD.

Cancer Screening for Transsexual Individuals

Professional organizations such as the American Cancer Society, American College of Obstetricians and Gynecologists and the US Preventive Services Task Force provide recommended cancer screening guidelines to facilitate clinical decision-making by professional providers. Some cancer screening protocols are sex/gender specific based on assumptions about the genitalia for a particular gender. There is little data on cancer risk specifically in transsexual individuals.

 

There is difficulty in recommending sex/gender specific screenings (e.g., breast, cervix, ovaries, penis, prostate, testicles, and uterus) for transsexual individuals because of their physiologic changes. For example, transmen who have not undergone a mastectomy have the same risks for breast cancer as natal women. In transwomen, the prostate typically is not removed as part of genital surgery, so individuals who do not take feminizing hormones may be at the same risk for prostate cancer as natal men. Therefore, cancer screenings (e.g., mammograms, prostate screenings) may be indicated based on the individual`s original gender.

Gender specific screenings may be medically necessary for transgender persons appropriate to their anatomy. Examples include:

-        Breast cancer screening may be medically necessary for transmen who have not undergone a mastectomy.

-        Prostate cancer screening may be medically necessary for transwomen who have retained their prostate.

Addendum: 

Effective 08/01/2017:  Added specific gender identity disorder diagnoses codes under the broader umbrella of Gender Dysphoria for clarification purposes.  Clarified examples of excluded cosmetic surgeries.