NOTE: If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
DESCRIPTION
Gender reassignment surgery is a term used to describe multiple medical and/or surgical treatments related to alleviating gender dysphoria. Gender is a term that refers to the psychological and cultural characteristics associated with biological sex. It is a psychological concept and sociological term, not a biological one. Gender identity refers to an individual’s awareness of being male or female and is sometimes referred to as an individual’s “experienced gender.” Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s biology.
According to the Standards of Care for the Health of Transgender, and Gender-Nonconforming People, Version 8 provided by the World Professional Association for Transgender Health treatment options for gender dysphoria may include:
Psychotherapy (individual, couple, family, or group) for purposes such as exploring gender identity, role, and expression; addressing the negative impact of gender dysphoria and stigma on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; or promoting resilience.
Changes in gender expression and role, which may involve living part time or full time in another gender role, consistent with one’s gender identity;
Hormone therapy to feminize or masculinize the body;
Surgery to change primary and/or secondary sex characteristics (e.g., breasts/chest, external and/or internal genitalia, facial features, body contouring);
Definitions:
Gender identity: An individual’s internal sense of gender, which may be male, female, neither, or a combination of male and female, and which may be different from an individual’s sex assigned at birth.
Gender-nonconforming: Individual whose gender identity, role, or expression differs from what is normative for their biology in a given culture and historical period
Transgender: Individuals who cross or transcend culturally defined categories of gender. The gender identity of transgender people differs to varying degrees from their biologic sex
Gender-Affirmation Surgery: Used to describe surgery to change primary and/or secondary sex characteristics to affirm a person’s gender identity.
Refer to the Gender Reassignment Precertification Request Form
POLICY
Gender reassignment surgery, non-binary affirmation surgery is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Other procedures, including but not limited to the following, are considered cosmetic when performed in association with gender reassignment surgery:
abdominoplasty
blepharoplasty
subsequent breast enlargement procedures, including augmentation mammoplasty, implants, and silicone injections of the breast
brow lift
calf implants
cheek/malar implants
chin/nose implants
collagen injections
electrolysis
face/forehead lift
hair removal/hair transplantation
jaw shortening/sculpturing/facial bone reduction
laryngoplasty
lip reduction/enhancement
liposuction
mastopexy
neck tightening
pectoral implants
removal of redundant skin
replacement of tissue expander with permanent prosthesis testicular insertion
rhinoplasty
subsequent phalloplasty (i.e. surgery to insert erectile prosthesis or improve appearance)
skin resurfacing (e.g., dermabrasion, chemical peels)
surgical correction of hydraulic abnormality of inflatable (multi-component) prosthesis including pump and/or cylinders and/or reservoir
testicular expanders
trachea shave/reduction thyroid chondroplasty
voice modification surgery
voice therapy/voice lessons
MEDICAL APPROPRIATENESS
Gender reassignment surgery, non-binary affirmation surgery or gender reassignment surgery reversal is considered medically appropriate if ALL of the following are met:
Individual is 18 years or older
Individual has the capacity to make a fully informed consent to treatment
Any significant medical concerns are well controlled (e.g., hypertension, diabetes, coronary artery disease)
Individual understands the effects of surgical intervention on potential reproduction and the individual’s reproduction options have been discussed.
Other possible causes of apparent gender incongruence have been identified and excluded
Any significant mental health concerns are well controlled (e.g., anxiety, depression, conduct disorder, substance abuse, dissociative identity disorders, borderline personality disorder)
The Gender Reassignment Gender Reassignment Precertification Request Form completed and submitted with the request for authorization
Documentation shows persistent and well documented gender dysphoria as evidenced by ALL of the following (DSM-V definition):
The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by TWO OR MORE of the following:
A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
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
A strong desire for the primary and/or secondary sex characteristics of the other gender
A strong desire to be of the other gender
A strong desire to be treated as another gender or gender neutral
A strong conviction that one has the typical feelings and reactions of the other gender
Surgery is ANY ONE of the following:
Female to male gender reassignment if ANY ONE of the following are met:
Mastectomy with nipple/areola reconstruction surgery if ALL of the following are met:
One (1) referral letter from mental health professional with a minimum of a Master’s degree or its equivalent in a clinical behavioral science field (See ADDITIONAL INFORMATION for letter criteria)
Hysterectomy and ovariectomy surgery if ALL of the following are met:
Documentation of 6 months of continuous hormonal therapy (unless the individual has a medical contraindication or is unable or unwilling to take hormones).
Two (2) referral letters are needed from a mental health professional with a minimum of a Master’s degree or its equivalent in a clinical behavioral science field. If the first referral is from the patient’s psychotherapist, the second referral should be from the mental health professional that has only had an evaluative role with the patient. (See ADDITIONAL INFORMATION for letter criteria)
Metoidioplasty or phalloplasty surgery if ALL of the following are met:
Documentation of 6 months of continuous hormonal therapy (unless the individual has a medical contraindication or is unable or unwilling to take hormones).
Documentation shows that the individual has lived continuously for 12 months in a real-life experience, in the gender role that is congruent with their gender identity
Two (2) referral letters are needed from a mental health professional with a minimum of a Master’s degree or its equivalent in a clinical behavioral science field. If the first referral is from the patient’s psychotherapist, the second referral should be from the mental health professional that has only had an evaluative role with the patient. (See ADDITIONAL INFORMATION for letter criteria)
Male to female gender reassignment if ANY ONE of the following are met:
Breast augmentation with nipple/areola reconstruction surgery if ALL of the following are met:
One (1) referral letter from mental health professional with a minimum of a Master’s degree or its equivalent in a clinical behavioral science field (See ADDITIONAL INFORMATION for letter criteria)
Documentation of 6 months of continuous hormonal therapy (unless the individual has a medical contraindication or is unable or unwilling to take hormones).
Orchiectomy/penectomy surgery if ALL of the following are met:
Documentation of 6 months of continuous hormonal therapy (unless the individual has a medical contraindication or is unable or unwilling to take hormones).
Two (2) referral letters are needed from a mental health professional with a minimum of a Master’s degree or its equivalent in a clinical behavioral science field. If the first referral is from the patient’s psychotherapist, the second referral should be from the mental health professional that has only had an evaluative role with the patient. (See ADDITIONAL INFORMATION for letter criteria)
Vaginoplasty surgery if ALL of the following are met:
Documentation of 6 months of continuous hormonal therapy (unless the individual has a medical contraindication or is unable or unwilling to take hormones).
Documentation shows that the individual has lived continuously for 12 months in a real-life experience, in the gender role that is congruent with their gender identity
Two (2) referral letters are needed from a mental health professional with a minimum of a Master’s degree or its equivalent in a clinical behavioral science field. If the first referral is from the patient’s psychotherapist, the second referral should be from the mental health professional that has only had an evaluative role with the patient. (See ADDITIONAL INFORMATION for letter criteria)
Female or Male to Gender Neutral (Non-binary) affirmation surgery, if ANY ONE of the following are met:
Breast reduction or mastectomy if ALL the following are met:
One (1) referral letter from mental health professional with a minimum of a Master’s degree or its equivalent in a clinical behavioral science field (See ADDITIONAL INFORMATION for letter criteria)
Penectomy and/or orchiectomy if ALL the following are met:
Two (2) referral letters from mental health professional with a minimum of a Master’s degree or its equivalent in a clinical behavioral science field. If the first referral is from the patient’s psychotherapist, the second referral should be from the mental health professional that has only had an evaluative role with the patient. (See ADDITIONAL INFORMATION for letter criteria)
New procedures to be reviewed and considered for medical necessity as they become available
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
According to the Standards of Care for the Health of Transgender, and Gender-Nonconforming People, Version 8 provided by the World Professional Association for Transgender Health (WPATH) letter criteria for each referral letter should address ALL of the following topics:
Client’s general identifying characteristics
Results of the client’s psychosocial assessment, including assessment of gender dysphoria and any other diagnoses
The duration of the mental health professional relationship with the client, including the type of evaluation and therapy or counseling to date
Other options tried to alleviate gender dysphoria (e.g., individual therapy, group and/or family therapy, hormone therapy)
An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the individual’s request for surgery
A statement about the fact that informed consent has been obtained from the individual
A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this
SOURCES
American Academy of Child & Adolescent Psychiatry. (2012, September). Practice Parameter on Gay, Lesbian, or Bisexual Sexual Orientation, Gender Nonconformity, and Gender Discordance in Children and Adolescents. Retrieved June 2, 2017 from www.jaacap.org.
American Psychiatric Association. (2011, September). Report of the APA Task Force on Treatment of Gender Identity Disorder. Retrieved September 16, 2013 from https://www.psychiatry.org.
CMS.gov: Centers for Medicare & Medicaid Services. Palmetto GBA. (2021, January). Gender Reassignment Services for Gender Dysphoria. (LCA A53793). Retrieved September 27, 2021 from https://www.cms.gov.
Colebunders, B., Brondeel, S., D’Arpa, S., Hoebeke, P., & Monstrey, S. (2016). An update on the surgical treatment for transgender patients. Sexual Medicine Reviews, 16, 30032-30034. Abstract retrieved September 15, 2016 from PubMed database.
Delgado-Ruiz, R., Swanson, P., & Romanos, G. (2019). Systematic review of the long-term effects of transgender hormone therapy on bone markers and bone mineral density and their potential effects in implant therapy. Journal of Clinical Medicine, 8 (6), 784. (Level 2 evidence)
Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A., La°ngstro¨m, N., and Lande´n, M. (2011, February).
Djordjevic, M. L., Bizic, M. R., Duisin, D., Bouman, M. B., & Buncamper, M. (2016). Reversal surgery in regretful male-to-female transsexuals after sex reassignment surgery. Journal of Sexual Medicine, 13 (6), 1000-1007. Abstract retrieved September 15, 2016 from PubMed database.
European Society for Sexual Medicine. (2020). Position statement “assessment and hormonal management in adolescent and adult trans people, with attention for sexual function and satisfaction.” Retrieved November 20, 2020 from https://www.essm.org/.
Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLOS One, 6 (2), e16885. (Level 2 evidence)
Winifred S. Hayes, Inc. Medical Technology Directory. (2018, August; last update search August 2022). Sex reassignment surgery for the treatment of gender dysphoria. Retrieved November 1, 2022 from www.Hayesinc.com/subscribers. (92 articles and or guidelines reviewed)
World Professional Association for Transgender Health (WPATH). (2022). Standards of Care for the health of transgender, and gender-nonconforming people, version 8. Retrieved November 1, 2022 from https://www.wpath.org/soc8.
Zucker, K., Nabbijohn, A., Santarossa, A., Wood, H., Bradley, S., Matthews, J., & VanderLaan, D. (2017). Intense/obsessional interests in children with gender dysphoria: a cross-validation study using the Teacher’s Report Form. Child, Adolescent Psychiatry & Mental Health. 11 (15), 1-8. (Level 4 evidence)
ORIGINAL EFFECTIVE DATE: 10/10/2013
MOST RECENT REVIEW DATE: 3/27/2024
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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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