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Gender Affirming Surgery | |
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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.
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.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR, 2022) provides for one overarching diagnosis of gender dysphoria with separate specific criteria for children and for adolescents and adults.
The DSM-5-TR defines gender dysphoria in adolescents and adults as a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:
In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The DSM-5-TR defines gender dysphoria in children as a marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion):
As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
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Policy/ Coverage: |
Effective November 13, 2023, for contracts providing benefits AND subject to Act 575, a prior authorization is NOT required for any gender affirming surgery. For contracts not subject to Arkansas Act 575, a prior authorization is required.
Effective November 13, 2023
Coverage eligibility of Gender Affirming Surgery is a contract specific benefit issue.
When benefits for gender affirming surgery are available, coverage may vary and under some plans may be excluded.
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 AND meet all the following indications:
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 candidates requesting female to male
surgery see item 4 below):
4. For candidates requesting female to male surgery only:
5. The candidate has completed a minimum of 12 months of successful continuous full time real-life
experience in their new gender, without 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, 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.
The letter or letters from the candidate’s physician 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 candidate’s 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; AND
10. Demonstrable progress on the part of the candidate in consolidating the new gender identity,
including improvements in the ability to handle:
The letter or letters from the 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
4. The surgeon has personally communicated with the candidate and that the candidate understands
the ramifications or surgery, including:
When benefits are available, the following gender reassignment surgeries---alone or in combination--
are covered:
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:
Effective March 2022 - November 12, 2023
Coverage eligibility of Gender Affirming Surgery is a contract-specific benefit issue.
When benefits for gender affirming surgery are available, coverage may vary and under some plans may be excluded.
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 AND meet all the following indications:
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 candidates requesting female to male surgery see item 4 below):
4. For candidates requesting female to male surgery only:
5. The candidate has completed a minimum of 12 months of successful continuous full time real-life experience in their new gender, without 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, 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.
The letter or letters from the candidate’s physician 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 candidate’s 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; AND
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:
The letter or letters from the 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
4. The surgeon has personally communicated with the candidate and that the candidate understands the ramifications or surgery, including:
When benefits are available, the following gender reassignment surgeries---alone or in combination-- are covered:
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:
Other surgery exclusions include but are not limited to:
Effective January 2017 through February 2022
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:
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):
4. For candidates requesting female to male surgery only:
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.
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:
Other surgery exclusions include but are not limited to:
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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.
2020 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2020. No new literature was identified that would prompt a change in the coverage statement.
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2021. No new literature was identified that would prompt a change in the coverage statement.
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2022. No new literature was identified that would prompt a change in the coverage statement.
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through September 2023. No new literature was identified that would prompt a change in the coverage statement.
In September 2022, World Professional Association for Transgender Health published Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.
In 2022, DSM-F-TR Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR, 2022) updated its diagnostic criteria of gender dysphoria and outlined separate specific criteria for children and for adolescents and adults.
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CPT/HCPCS: | |
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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. World Professional Association for Transgender Health.(2022) Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health; Accessed at: https://www.wpath.org/soc8 |
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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 © 2024 American Medical Association. |