CAM 145

Gender Reassignment Surgery

Category:Surgery   Last Reviewed:January 2019
Department(s):Medical Affairs   Next Review:January 2020
Original Date:March 2016    

Description
Gender dysphoria disorder is the formal diagnosis used by professionals to describe persons who experience significant gender dysphoria (discontent with their biological sex and/or birth gender).

DSM V criteria:
1. Discomfort with one’s assigned sex or gender role for period of at least six months, as manifested by at least two of the following indicators:

a. Feeling of incongruence between one’s felt gender identity and one’s primary and secondary sex characteristics;
b. Desire to be rid of one's primary and secondary sex characteristics;
c. Desire for the sex characteristics of the other sex;
d. Desire to be the other sex;
e. Desire to be treated as the other sex;
f. Belief that one has the feelings and reactions typical of the other sex.

2. The individual does not have an intersex or developmental condition;
3. The condition causes clinically significant distress or impairment in social, occupational or other areas of functioning;
4. "Gender dysphoria disorder not otherwise specified" is proposed to include individuals who cannot be diagnosed as having a specific gender dysphoria disorder but experience distress and impairment as a result of their gender identity.

Policy 
Benefits are limited to commercial groups with coverage for gender dysphoria. 

When a benefit for gender reassignment surgery exists, it is considered a covered service when the documentation submitted confirms that all of the following eligibility criteria are met:

  • The individual is at least 18 years of age, AND 
  • The individual has been diagnosed with the gender dysphoria based on the current edition of the Diagnostic and Statistical Manual of Mental Disorders, AND
  • The individual initially has successfully lived and worked within the desired gender role full-time for at least 12 months (real-life experience) without returning to the original gender, AND
  • In addition to living and working with the desired gender role full-time for a minimum of 12 months, a minimum of an additional 12 continuous months of hormone replacement therapy must occur, AND 
  • After the minimum of 24 continuous months of living and working within the desired gender role full-time and hormone replacement therapy, the individual should undergo repeat comprehensive independent behavioral health evaluation.
  • Regular psychotherapy and counseling should be available through the member's individualized gender reassignment pathway.  

Surgical Treatment for Gender Reassignment

When a covered benefit for gender reassignment surgery exists and all of the above eligibility criteria are met, the following surgeries are Medically Necessary  for transwomen (male to female):

  • Orchiectomy (54520, 54690)
  • Penectomy (54125)
  • Vaginoplasty (57335)
  • Colovaginoplasty (57291-57292)
  • Clitoroplasty (56805)
  • Labiaplasty (58999)
  • Breast Augmentation (19324-19325) Note: augmentation mammoplasty (including breast prosthesis if necessary) if the physician prescribing hormones and the surgeon have documented that breast enlargement after undergoing hormone treatment for 12 months is not sufficient for comfort in the social role
  • Trachea shave/reduction thyroid chondroplasty: reduction of the thyroid cartilage (31899)

When a covered benefit for gender reassignment surgery exists and all of the above eligibility criteria are met, the following surgeries are Medically Necessary for transmen (female to male):

  • Breast reconstruction (e.g., mastectomy (19303-19304), reduction mammoplasty (19318))
  • Hysterectomy (58150, 58262, 58291, 58552, 58554, 58571, 58573)
  • Salpingo-oophorectomy (58661)
  • Colpectomy/Vaginectomy (57110)
  • Metoidioplasty (55899)
  • Phalloplasty (55899)
  • Urethroplasty (53430)
  • Scrotoplasty (55175, 55180) 
  • Testicular prosthesis (54660)

Other services (e.g., laboratory, pharmacy, radiology or behavioral health services) are covered according to the plan design.

For all Commercial products that do not have benefit coverage for Gender Dysphoria
Gender reassignment surgery is a contract exclusion and is non-covered.

The following procedures are considered cosmetic services and are non-covered:

  • Abdominoplasty
  • Brow ptosis surgery
  • Cervicoplasty
  • Chemical exfoliations, peels, abrasions (or dermabrasions or planing for acne, scarring, wrinkling, sun damage or other benign conditions
  • Correction of variations in normal anatomy, including augmentation mammoplasty, mastopexy and correction of congenital breast asymmetry
  • Dermabrasion
  • Ear piercing or repair of a torn earlobe
  • Excision of excess skin or subcutaneous tissue (except panniculectomy as listed above)
  • Genioplasty
  • Gynecomastia surgery
  • Hair transplants
  • Hair removal (including electrolysis epilation)
  • Inverted nipple surgery
  • Laser treatment for acne and acne scars
  • Osteoplasty - facial bone reduction
  • Otoplasty
  • Procedures to correct visual acuity, including, but not limited to, cornea surgery or lens implants
  • Removal of asymptomatic benign skin lesions
  • Repeated cauterizations or electrofulguration methods used to remove growths on the skin
  • Rhinoplasty
  • Rhytidectomy
  • Scar revision, regardless of symptoms
  • Sclerotherapy for spider veins
  • Subcutaneous injection of filling material
  • Suction-assisted lipectomy
  • Tattooing or tattoo removal (except tattooing of the nipple/areola related to a mastectomy)
  • Treatment of vitiligo
  • Voice modification surgery
  • Reversal of genital surgery or reversal of surgery to revise secondary sex characteristics

Policy Guidelines 
Therapeutic approaches include psychological interventions and gender reassignment therapy, including hormonal interventions that masculinize or feminize the body, and surgical interventions  that change the genitalia and other sex characteristics. Gender dysphoria disorders may manifest at childhood, adolescence or adulthood. There is not evidence from scientific study to support either approach. 

Individuals diagnosed with GDD must undertake real-life experience living in the identity-congruent gender role. This provides sufficient opportunity for patients to experience and socially adjust in their desired role before undergoing irreversible surgery. During this experience, patients should present themselves consistently, on a day-to-day basis and across all life settings, in their desired gender role. Changing gender role can have profound personal and social consequences, and individuals must demonstrate an awareness of the challenges and the ability to function successfully in their gender role.

Prior to surgery, patients typically undergo hormone replacement therapy for a period of 12 continuous months. Transmen are treated with testosterone to increase muscle and bone mass, decrease breast size, increase clitoris size, increase facial and body hair, arrest menses and deepen the voice. Transwomen are treated with anti-androgens and estrogens to increase percentage of body fat compared to muscle mass, decrease body hair, decrease testicular size, decrease erectile function and increase breast size.

Gender reassignment surgery may be considered as a treatment option for individuals who have completed at least 24 continuous months living and working in the desired gender role and at least 12 months of hormone replacement therapy. GRS is not a single procedure, but part of a complex process involving multiple medical, psychiatric and surgical modalities performed in conjunction with each other to help the candidate for gender reassignment achieve successful behavioral and medical outcomes. Before undertaking GRS, candidates need to undergo important medical and psychological evaluations, and begin medical therapies and behavioral trials to confirm that surgery is the most appropriate treatment choice. 

The surgical procedures for male-to-female individuals, also known as "transwomen," may include: orchiectomy, penectomy, vaginoplasty, clitoroplasty, labioplasty breast augmentation, trachea shave/reduction thyroid chondroplasty and techniques include penile skin inversion, pedicled colosigmoid transplant and free skin grafts to line the neovagina. For female-to-male persons, also known as "transmen," surgery may include hysterectomy, ovariectomy, vaginectomy, salpingooophorectomy, metoidioplasty, scrotoplasty, urethroplasty, placement of testicular prostheses and phalloplasty.

In 2009 the Endocrine Society published a clinical practice guideline for endocrine treatment of transsexual persons (Hembree et al., 2009). As part of this guideline, the endocrine society recommends that transsexual persons consider genital sex reassignment surgery only after both the physician responsible for endocrine transition therapy and the mental health professional find surgery advisable; that surgery be recommended only after completion of at least one year of consistent and compliant hormone treatment; and that the physician responsible for endocrine treatment advise the individual for sex reassignment surgery and collaborate with the surgeon regarding hormone use during and after surgery.

Sex reassignment surgical procedures for diagnosed cases of GID should be recommended only after a comprehensive evaluation by a qualified mental health professional. The surgeon should have a demonstrated competency and extensive training in sexual reconstructive surgery. Long-term follow-up is highly recommended.

Comprehensive evaluation is generally supported by the following documentation:

1. Letters that attest to the psychological aspects of the candidate’s GDD.

1a.  One of the letters must be from a behavioral health professional with a doctoral degree (who is capable of adequately evaluating if the candidate has any comorbid psychiatric conditions);

1b.  One of the letters must be from the candidate’s physician or behavioral health provider, who has treated the candidate for a minimum of 12 months (Note: if the candidate has not been treated continuously by one clinician for 12 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 12 months). The letter or letters must document the following:

  1. Whether the author of the letter is part of a gender dysphoria 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, 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. For candidates not meeting the 12-month eligibility criteria, the letter should still comment on the candidate’s ability to function and experience in the desired gender 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:
    1. Work, family and interpersonal issues;
    2. Behavioral health issues, should they exist. This implies satisfactory control of issues such as:
      • Sociopathy
      • Substance abuse
      • Psychosis
      • Suicidality
  • 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;
  • 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 eligibility 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 of surgery.

References 

  1. Becker S, Bosinski HAG, Clement U, Eicher WM, Goerlich TM, Hartmann U, et al. (1998) German standards for the treatment and diagnostic assessment of transsexuals. IJT 2/4. Available at URL address: http://www.symposion.com/ijt/ijtc0603.htm
  2. Day P. Trans-gender Reassignment Surgery. Tech Brief Series. New Zealand Health Technology Assessment. NZHTA Report February 2002, Volume 1, Number 1. Available at URL address: http://nzhta.chmeds.ac.nz/index.htm#tech
  3. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. Text Revision (DSM-IV -TR). American Psychiatric Association. American Psychiatric Association, Incorporated. July 2000.
  4. I Institute. Hotline Response [database online]. Plymouth Meeting (PA): ECRI Institute; 2007 October. Sexual reassignment for gender identity disorders. Available at URL address: http://www.ecri.org
  5. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer WJ 3rd, Spack NP, Tangpricha V, Montori VM; Endocrine Society. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
  6. Landen M, Walinder J, Hambert G, Lundstrom B. Factors predictive of regret in sex reassignment. Acta Psychiatr Scand. 1998 Apr;97(4):284-9.
  7. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003 Aug;32(4):299-315.
  8. Maharaj NR, Dhai A, Wiersma R, Moodley J. Intersex conditions in children and adolescents: surgical, ethical, and legal considerations. J Pediatr Adolesc Gynecol. 2005 Dec;18(6):399-402.
  9. Moore E, Wisniewski A, Dobs A. Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects. J Clin Endocrinol Metab. 2003 Aug;88(8):3467-73.
  10. Smith YL, van Goozen SH, Cohen-Kettenis PT. Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study. J Am Acad Child Adolesc Psychiatry. 2001 Apr;40(4):472-81.
  11. Sutcliffe PA, Dixon S, Akehurst RL, Wilkinson A, Shippam A, White S, Richards R, Caddy CM. Evaluation of surgical procedures for sex reassignment: a systematic review. J Plast Reconstr Aesthet Surg. 2009 Mar;62(3):294-306; discussion 306-8.
  12. World Professional Association for Transgender Health. The Harry Benjamin International Gender Dysphoria Association. Standards of Care for Gender Identity Disorders. 6th version. 2001 Feb. Available at URL address: http://www.wpath.org/publications_standards.cfm
  13. Zucker KJ. Intersexuality and gender identity disorder. J Pediatr Adolesc Gynecol. 2002 Feb;15(1):3-13

Coding Section 

Code Number Description
CPT

19301

Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy)

 

19303

Mastectomy, simple, complete

 

19304

Mastectomy, subcutaneous

 

19316 

Mastopexy

 

19324

Mammaplasty, augmentation; without prosthetic implant 

 

19325

Mammaplasty, augmentation; with prosthetic implant 

 

19350

Nipple/areola reconstruction 

 

31899

Unlisted procedure, trachea, bronchi 

 

53430

Urethroplasty, reconstruction of female urethra 

 

54125 

Amputation of penis; complete 

 

54520 

Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach 

 

54660 

Insertion of testicular prosthesis (Separte Procedure)  

 

54690 

Laparoscopy, surgical; orchiectomy 

 

55175

Scrotoplasty; simple 

 

55180 

Scrotoplasty; complicated 

 

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 

 

56810 

Perineoplasty, repair of perineum, nonobstetrical (separate procedure) 

 

57106 

Vaginectomy, partial removal of vaginal wall 

 

57107 

Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) 

 

57110 

Vaginectomy, complete removal of vaginal wall 

 

57111 

Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) 

 

57291 

Construction of artificial vagina; without graft 

 

57292 

Construction of artificial vagina; with graft 

 

57335 

Vaginoplasty for intersex state 

 

58150 

Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) 

 

58180 

Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) 

 

58260 

Vaginal hysterectomy, for uterus 250 g or less 

 

58262 

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

 

58275 

Vaginal hysterectomy, with total or partial vaginectomy 

 

58280 

Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele 

 

58285 

Vaginal hysterectomy, radical (Schauta type operation) 

 

58290 

Vaginal hysterectomy, for uterus greater than 250 g 

 

58291 

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

 

58541 

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less 

 

58542 

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

 

58543 

Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g 

 

58544 

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

 

58550 

Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less 

 

58552 

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

 

58553 

Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g

 

58554 

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

 ICD-9 Diagnosis 

302.6

Gender dysphoria in children, other specified or unspecified gender dysphoria 

 

302.85 

Gender dysphoria in adolescents and adults 

ICD-10-CM 

F64.0 

Transsexualism 

 

F64.2, F64.8, F64.9

Gender dysphoria in children, other specified or unspecified gender dysphoria 

 

F64.1 

Gender dysphoria in adolescents and adults 

 

Z87.890

Personal history of sex reassignment 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2016 Forward     

01/02/2019 

Annual review, no change to policy intent.  

08/07/2018 

Interim review, updating the minimum age criteria from 21 to 18 for these procedures. No other changes made. 

01/03/2018 

Annual review, no change to policy intent. 

06/26/2017 

Interim review, adding CPT codes 55970 & 55980 to the policy. 

05/25/2017 

Added code F64.0 to coding section. No other changes made. 

05/16/2017 

Interim review to update language regarding diagnosis. 

05/01/2017 

Updated coding. No other changes made. 

06/01/2016 

Corrected formatting 

03/22/2016

NEW POLICY


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