Commercial

Medical Policy

Notification

Gender Affirming Interventions

Notification Issued Date:

This version of the policy will become effective 01/01/2020.

This policy has been identified for the CPT code update, effective 01/01/2020.

The following code has been DELETED from the policy:

19304

Title:

Gender Affirming Interventions

Policy #:

11.09.02o

Policy

MEDICALLY NECESSARY

GENDER AFFIRMING INTERVENTIONS ARE SERVICES FOR AN INDIVIDUAL WHO HAVE A LONG-LASTING AND INTENSE PATTERN OF GENDER NONCONFORMITY, GENDER INCONGRUENCE, GENDER DYSPHORIA, OR IS GENDER DIVERSE. SEE GUIDELINES SECTION FOR FULL DEFINITIONS.

PUBERTY-SUPPRESSING HORMONES
Puberty-suppressing hormones (e.g., Supprelin LA® [histrelin acetate], Vantas® [histrelin acetate], Lupron Depot® [leuprolide acetate for depot suspension], Viadur® [leuprolide acetate implant], Eligard® [leuprolide acetate for injectable suspension], Zoladex® [goserelin acetate implant], Trelstar® [triptorelin pamoate for injectable suspension]) are considered medically necessary and, therefore, covered, when all of the following criteria are met:

The adolescent has met the definition of gender nonconformity, gender incongruence, gender dysphoria, or is gender diverse.
The individual has reached at least Tanner Stage 2 of development.
If an individual has a diagnosis of gender dysphoria, the gender dysphoria emerged or worsened with the onset of puberty.

Note: Subject to the terms, conditions, and limitations of the member’s contract, oral and self-administered hormones are not covered under the medical benefit.

CONTINUOUS HORMONE REPLACEMENT THERAPY
Continuous hormone replacement therapy (e.g., testosterone enanthate, testosterone pellet, estradiol valerate or medroxyprogesterone acetate) is considered medically necessary and, therefore, covered when all of the following criteria are met:

The individual has persistent, documented gender nonconformity, gender incongruence, gender dysphoria or is gender diverse.

Note: Subject to the terms, conditions, and limitations of the member’s contract, oral and self-administered hormones are not covered under the medical benefit.

BILATERAL MASTECTOMY
Bilateral mastectomy is considered medically necessary and, therefore, covered, when all of the following criteria are met:

The individual has persistent, documented gender nonconformity, gender incongruence, gender dysphoria or is gender diverse.
Bilateral mastectomy is recommended by a qualified professional provider with appropriate competencies and who has consistently monitored the individual up to the time of surgery.
- One referral letter and/or chart documentation must be written from the behavioral health professional provider who consistently monitored the individual throughout their psychotherapy or any other evaluation to the professional provider who will be responsible for the individual's treatment.
The individual is at least 18 years of age. If under age 18, refer to the policy statement below for additional coverage criteria.
The individual, if required by the behavioral health professional provider, has regularly participated in psychotherapy throughout a real-life experience (living in a gender role that is congruent with an individual's gender identity) at a frequency determined jointly by the individual and the behavioral health professional provider.
If the individual has significant medical or behavioral health concerns, they are reasonably well controlled.

BILATERAL REDUCTION MAMMOPLASTY

Bilateral reduction mammoplasty is considered medically necessary and, therefore, covered, when all of the following criteria are met:

The individual has persistent, documented gender nonconformity, gender incongruence, gender dysphoria or is gender diverse.
Bilateral reduction mammoplasty is recommended by a qualified professional provider with appropriate competencies who has consistently monitored the individual up to the time of surgery.
- One referral letter and/or chart documentation must be written from the behavioral health professional provider who consistently monitored the individual throughout their psychotherapy or any other evaluation to the professional provider who will be responsible for the individual's treatment.
The individual is at least 18 years of age. If under age 18, refer to the policy statement below for additional coverage criteria.
The individual, if required by the behavioral health professional provider, has regularly participated in psychotherapy throughout a real-life experience (living in a gender role that is congruent with an individual's gender identity) at a frequency determined jointly by the individual and the behavioral health professional provider.
If the individual has significant medical or behavioral health concerns, they are reasonably well controlled.

BREAST AUGMENTATION
Breast augmentation is considered medically necessary and, therefore, covered, when all of the following criteria are met:

The individual has persistent, documented gender nonconformity, gender incongruence, gender dysphoria or is gender diverse.
Breast augmentation is recommended by a qualified professional provider with appropriate competencies who has consistently monitored the individual up to the time of surgery.
- One referral letter and/or chart documentation must be written from the behavioral health professional provider who consistently monitored the individual throughout their psychotherapy or any other evaluation to the professional provider who will be responsible for the individual's treatment.
The individual is at least 18 years of age. If under age 18, refer to the policy statement below for additional coverage criteria.
The individual, unless not clinically indicated or medically contraindicated, has used feminizing hormones continuously and responsibly (which may include screenings and follow-ups with the professional provider) for a 12-month period.
The individual, if required by a behavioral health professional provider, has regularly participated in psychotherapy throughout a real-life experience (living in a gender role that is congruent with an individual's gender identity) at a frequency determined jointly by the individual and the behavioral health professional provider.
If the individual has significant medical or behavioral health concerns, they are reasonably well controlled.

GENDER AFFIRMING CHEST SURGERY FOR INDIVIDUALS UNDER AGE 18

Gender affirming chest surgery (i.e., mastectomy, reduction mammoplasty, or breast augmentation) for individuals under age 18 may be considered medically necessary when the above criteria for the appropriate chest surgical procedure have been met, and all of the following criteria are met:

The individual undergoing the procedure, their legal guardians, and their behavioral health professional are in agreement that gender affirming chest surgery is appropriate.
Involvement of parent(s)/guardian(s) in the assessment/consent process has been obtained and documented.
An assessment of the individual's emotional and cognitive maturity has been performed to evaluate their ability to provide informed consent/assent for the treatment, they are prepared for the surgery and that they have the understanding of the potential risks associated.
Assessment of the individual's physical development (skeletal maturity on a validated assessment tool, e.g., the Greulich and Pyle [GP] atlas, Tanner-Whitehouse [TW2] method, or the Gilsanz and Ratibin [GR] atlas) has been performed to evaluate their developmental readiness for surgery has been performed to evaluate their developmental readiness for surgery.
The individual has been living full time as the gender in which the individual identifies for at least 12 months. Improvement in symptoms when living as the gender in which the individual identifies has been confirmed by a letter from a behavioral health professional provider.

NIPPLE RECONSTRUCTION

Nipple reconstruction, including tattooing, following a gender affirming mastectomy, reduction mammoplasty, or breast augmentation is considered medically necessary and, therefore, covered when all of the criteria for the mastectomy, mammoplasty, or breast augmentation are met.

GENITAL RECONSTRUCTIVE SURGERY
Genital reconstructive surgery is considered medically necessary and, therefore covered, when all of the following criteria are met:

The individual has persistent, documented gender nonconformity, gender incongruence, gender dysphoria or is gender diverse.
Genital reconstructive surgery is recommended by a qualified health professional provider with the appropriate competencies and who has consistently monitored the individual up to the time of surgery.

One referral letter and/or chart documentation must be written from the behavioral health professional provider who consistently monitored the individual throughout their psychotherapy or any other evaluation and provided to the professional provider who will be responsible for the individual's treatment.

The individual is at least 18 years of age.
The individual, unless not clinically indicated or medically contraindicated, has used cross-gender hormone therapy continuously and responsibly (which may include screenings and follow-ups with the professional provider) for a 12-month period.
The individual has demonstrated successful, continuous full-time, real-life experience living in a gender role that is congruent with an individual's gender identity (i.e., the act of fully adopting a new or evolving gender role or gender presentation in everyday life) for a 12-month period.
The individual, if required by the behavioral health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the behavioral health professional provider.
If the individual has significant medical or behavioral health concerns, they are reasonably well controlled.

When all of the above criteria are met, the following genital reconstructive surgeries are covered:

Clitoroplasty
Coloproctostomy
Hysterectomy
Labiaplasty
Orchiectomy/Scrotoplasty
Penectomy/Phalloplasty/Metoidioplasty
Penile prosthesis implantation
Perineoplasty
Salpingo-oophorectomy
Testicular prostheses implantation
Vaginectomy/Vaginoplasty
Vulvectomy/Vulvoplasty
Urethroplasty

FACIAL AND NECK RECONSTRUCTIVE INTERVENTIONS

Facial and neck reconstructive interventions (facial masculinizing/facial feminizing interventions) listed below are considered medically necessary and therefore, covered when all of the following criteria are met:

The individual has persistent, documented gender nonconformity, gender incongruence, gender dysphoria or is gender diverse.
Facial and/or neck reconstructive interventions are recommended by a qualified health professional provider who has appropriate competencies and who has consistently monitored the individual up to the time of surgery.

One referral letter and/or chart documentation must be written from the behavioral health professional provider who consistently monitored the individual throughout their psychotherapy or any other evaluation to the professional provider who will be responsible for the individual's treatment.

The individual is at least 18 years of age.
The individual, if required by the behavioral health professional provider, has regularly participated in psychotherapy throughout a real-life experience (living in a gender role that is congruent with an individual's gender identity) at a frequency determined jointly by the individual and the behavioral health professional provider.
If the individual has significant medical or behavioral health concerns, they are reasonably well controlled.

When the above criteria are met, the following facial and neck reconstructive interventions are covered:

Blepharoplasty
Cervicoplasty/platysmaplasty
Chin augmentation (genioplasty, mentoplasty)
Face bone reduction
Facial prosthesis (e.g., nasal, orbital)
Forehead reduction
Lip reduction/enhancement
Orthognathic procedures
Rhinoplasty
Rhytidectomy*
Septoplasty
Trachea shave/reduction thyroid chondroplasty

*Rhytidectomy may be covered following alteration of the underlying skeletal structures as a result of a reconstructive gender affirming facial intervention.

Facial interventions to reverse natural signs of aging or if the individual is not satisfied with the aesthetic result of the gender affirming intervention are considered cosmetic and, therefore, not eligible for reimbursement consideration.

GENDER AFFIRMING VOICE MODIFICATION

Gender affirming voice modification surgery is considered medically necessary and therefore, covered when and the following criteria are met:

The individual has persistent, documented gender nonconformity, gender incongruence, gender dysphoria or is gender diverse.
Voice modification surgery (i.e., laryngoplasty, cricothyroid approximation) is recommended by a qualified health professional provider who has appropriate competencies and who has consistently monitored the individual up to the time of surgery.

One referral letter and/or chart documentation must be written from the behavioral health professional provider who consistently monitored the individual throughout their psychotherapy or any other evaluation to the professional provider who will be responsible for the individual's treatment.

The individual is at least 18 years of age.
The individual, if required by the behavioral health professional provider, has regularly participated in psychotherapy throughout a real-life experience (living in a gender role that is congruent with an individual's gender identity) at a frequency determined jointly by the individual and the behavioral health professional provider.
If the individual has significant medical or behavioral health concerns, they are reasonably well controlled.

Gender affirming voice modification therapy is considered medically necessary and therefore, covered when and the following criteria are met:

The individual has persistent, documented gender nonconformity, gender incongruence, gender dysphoria or is gender diverse.

HAIR REMOVAL/ELECTROLYSIS

Hair removal/electrolysis is considered medically necessary and, therefore, covered when required for skin preparation for gender reconstructive surgery (e.g., electrolysis of free flap or other donor skin sites for breast and genital reconstructive surgery).

GARMENTS

Garments, such as chest binders, chest padding, mastectomy bras, genital tuckers, are covered and eligible for reimbursement consideration by the Company for a quantity limit total of 12 of each garment in a 12-month period.

NEW YORK MEMBERS
The following applies to members covered under a fully insured benefit contract issued in the state of New York.

In accordance with state regulatory requirements for members enrolled in New York's commercial products, coverage of services performed in connection with gender transition, to more closely conform secondary sex characteristics to those of the member's identified gender (listed as Potentially Cosmetic in Attachment A), will be reviewed on a case-by-case basis. To be considered for coverage, all of the following must apply:

All requirements for genital reassignment surgery in accordance with the medical policy have been met

Services will be performed for the treatment of gender dysphoria

The clinical rationale for each requested procedure must be specifically documented in letters of recommendation from both the treating professional provider and the behavioral health professional provider

Treatments directed solely at improving an individual's physical appearance when not associated with gender dysphoria will be considered cosmetic. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

See Attachment A for a list of interventions requiring clinical documentation by the treating professional provider and behavioral health professional provider for members covered under a fully insured benefit contract issued in the state of New York.

MEDICALLY NECESSARY GENDER-SPECIFIC SERVICES

Gender-specific services may be medically necessary for transgender individuals as appropriate to their anatomy (e.g., mammograms, prostate cancer screening).

POTENTIALLY COSMETIC

The following procedures/therapies may be performed in combination with other surgeries for the treatment of gender dysphoria and are considered cosmetic or potentially cosmetic services, unless medical necessity demonstrating a functional impairment can be identified. Services that are cosmetic, following medical necessity review, are a benefit contract exclusion for all products of the Company and, therefore, not eligible for reimbursement consideration. This list is subject to change; refer to Company policy that addresses cosmetic services.

Abdominoplasty
Body-contouring procedures (e.g., liposuction, lipectomy)
Botox injections
Calf implantation
Cervicoplasty/platysmaplasty
Chin augmentation (genioplasty, mentoplasty)
Collagen injections
Dermabrasions/chemical peels
Excision of redundant skin
Gluteal augmentation (e.g., silicone implants, fat transfer, fat grafting)
Hair reconstruction (e.g., hair removal/electrolysis, hair transplantation, wigs), except during skin preparation for gender reconstructive surgical procedures
Injectable dermal fillers (e.g., Sculptra, Radiesse)
Otoplasty
Pectoral implantation
Tattooing (nontherapeutic)

Specific Company medical policies may exist for medical necessity criteria for noncosmetic uses of a potentially cosmetic procedure. Please refer to such individual policies for criteria that address cosmetic services.

EXPERIMENTAL/INVESTIGATIONAL

GENITAL/REPRODUCTIVE ORGAN TRANSPLANTATION
Genital and reproductive organ transplantation (e.g., penile or uterine), is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

LETTERS OF RECOMMENDATION

The behavioral health professional provider's recommendation letter for surgery should include all of the following:

The individual's general identifying characteristics
The initial and evolving gender, sexual, and other psychiatric diagnoses
The duration of their professional relationship, including the type of psychotherapy or evaluation that the individual underwent
The eligibility criteria that have been met and the behavioral health professional provider's rationale for hormone therapy or surgery
The degree to which the individual has followed the eligibility criteria to date and the likelihood of future compliance
Whether the author of the letter is part of a gender team
The sender welcomes a phone call to verify the fact that the behavioral health professional provider actually wrote the letter as described in this document

The letter of recommendation should be from a psychiatrist or a PhD-level clinical psychologist, who can be expected to adequately evaluate co-morbid psychiatric conditions.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, gender affirming interventions are covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.

Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

GENDER INCONGRUENCE, GENDER DYSPHORIA AND GENDER DIVERSE

Gender incongruence is a diagnostic term that describes a person’s marked and persistent experience of an incompatibility between that person’s gender identity and the gender expected of them based on their birth-assigned sex.

Gender dysphoria, as defined by the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, fifth edition text revision (DSM-5 TR), is an adolescent or adult with 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:

A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated 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 (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
A strong desire for the primary and/or secondary sex characteristics of the other gender
A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
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)

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.

Gender diverse is a term to describe individuals with gender identities and/or expressions that are different from social and cultural expectations attributed to their sex assigned at birth.

Description

GENDER DYSPHORIA

Gender dysphoria, previously known as gender identity disorder, is the distress that may accompany the incongruence between one’s experienced/expressed gender and one’s assigned gender (gender at birth or natal gender).

GENDER DIVERSE

Gender diverse is a term used to describe individuals with gender identities and/or expressions that are different from social and cultural expectations attributed to their sex assigned at birth. This may include, among many other culturally diverse identities, people who identify as nonbinary, gender expansive, gender nonconforming, and others who do not identify as cisgender.

DIAGNOSIS

CHILDREN
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, text revision (DSM-5 TR) diagnostic criteria for gender dysphoria in children is marked incongruence between one’s experienced and/or expressed gender and the assigned gender, of at least 6 months’ duration, as manifested by a strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender) AND at least five of the following:

In males (assigned gender), a strong preference to cross-dressing or simulating female attire; or in females (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
A strong preference for cross-gender roles in make-believe play or fantasy play
A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender
A strong preference for playmates of the other gender
In males (assigned gender), a strong rejection of typical masculine toys, games, and activities, and a strong avoidance of rough-and-tumble play; or in females (assigned gender), a strong rejection of typically feminine toys, games, and activities
A strong dislike of one’s sexual anatomy
A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender
Clinically significant distress or impairment in social, school, or other important areas of functioning

ADOLESCENTS AND ADULTS
The DSM-5 TR diagnostic criteria for gender dysphoria in adolescents and adults is marked incongruence between one's experienced and or expressed gender and assigned gender, of at least 6 months' duration as manifested by a strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender) AND at least two or more of the following indicators:

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 (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
A strong desire for the primary and/or secondary sex characteristics of the other gender
A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
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)
Clinically significant distress or impairment in social, occupational, or other important areas of functioning.

GENDER-AFFIRMING INTERVENTIONS

Gender-affirming interventions consist of medical and surgical treatments that change primary sex characteristics for individuals living with gender nonconformity, gender incongruence, gender dysphoria or who are gender diverse, such that the individual is able to align their physical primary and/or secondary sex traits with their gender identity and alleviate symptoms. Puberty-suppressing hormones, continuous hormone replacement therapy, bilateral mastectomy, breast augmentation, and genital reconstructive surgery are all considered gender affirming interventions. The process of changing one's gender is not one procedure but a complex process that may involve multiple stages (e.g., behavioral health interventions, experience living in the desired gender role, hormone therapy, and surgical options).

Behavioral health interventions may include integration of trans- or cross-gender feeling and expressions into the gender role, which may involve living in another gender role, consistent with one's gender identity.

Hormone therapy may include the use of masculinizing or feminizing hormones (e.g., testosterone enanthate, testosterone pellet, estradiol valerate, or medroxyprogesterone acetate) in adolescents and adults, or the use of puberty-suppressing hormones (e.g., Supprelin LA® [histrelin acetate], Vantas® [histrelin acetate], Lupron Depot® [leuprolide acetate for depot suspension], Viadur® [leuprolide acetate implant], Eligard® [leuprolide acetate for injectable suspension], Zoladex® [goserelin acetate implant], Trelstar® [triptorelin pamoate for injectable suspension]) in children.

Individuals who live with gender nonconformity, gender incongruence, gender dysphoria or who are gender diverse may undergo surgery to change chest structure, genitalia, and/or other characteristics. Typically, surgery is considered an irreversible physical intervention.

TRANSPLANTATION

UTERINE TRANSPLANTATION

Case reports of uterine transplantation procedures are emerging, primarily in the treatment of absolute uterine factor infertility. The early case reports have demonstrated individuals who undergo uterine transplantation have been able to sustain fetal growth and deliver a child. With the advent of the successful births via uterine transplantation, there has been considerations of performing uterine transplantation in transgender women motivated by the desire to gestate and give birth. The evidence for such an operation within this population is limited and reports of successful operations being performed were not discoverable. The evidence is insufficient to evaluate overall net health outcomes.

PENILE TRANSPLANTATION

Penile transplantation using vascularized composite allografts is an emerging technique to treat genital loss. The first penile transplantation occurred in 2006. To date, the literature suggests a few case reports have ever been produced worldwide. As such, the evidence is insufficient to evaluate overall net health outcomes for individuals receiving penile transplantation.

GENDER-SPECIFIC SERVICES

Professional organizations such as the American Cancer Society (ACS), the American College of Obstetricians and Gynecologists (ACOG), and the US Preventive Services Task Force (USPSTF) provide recommended screening guidelines to facilitate clinical decision-making by professional providers. Some screening protocols are sex/gender-specific based on assumptions about the anatomy for a particular gender. There is difficulty in recommending sex/gender-specific screenings (e.g., breast, prostate) for transgender individuals because of their physiologic changes. For example, transmen who have not undergone a mastectomy may have the same risks for breast cancer as a natal female. In transwomen, if the prostate is not removed as part of genital surgery, individuals may be at the same risk for developing prostate cancer as a natal male. Therefore, gender-specific services (e.g., mammograms, prostate screenings) may be indicated based on the individual's natal gender.

References

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American College of Obstetricians and Gynecologists (ACOG). Healthcare for transgender individuals. Committee Opinion. Obstet Gynecol. 2011:118:1454-1458.

American College of Obstetricians and Gynecologists (ACOG). Care for transgender adolescents [ACOG Web site]. March 2021. Available at: https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals.pdf. Accessed March 23, 2023.

American College of Obstetricians and Gynecologists' Committee on Gynecologic Practice; American College of
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Meyer W, Bockting W, Cohen-Kettenis P, et al. The Harry Benjamin International Gender Dysphoria Association's Standards of Care for Gender Identity Disorders, sixth version. The World Professional Association For Transgender Health Web site. 02/2001. Available at: http://www.cpath.ca/wp-content/uploads/2009/12/WPATHsocv6.pdf. Accessed March 23, 2023.

Monstrey SJ, Ceulemans P, Hoebeke P. Sex reassignment surgery in the female-to-male transsexual. Semin Plast Surg. 2011;25(3): 229-244.

Office for Civil Rights (OCR), Office of the Secretary, The Department of Health and Human Services (HHS). Nondiscrimination in Health Programs and Activities. Final rule. Fed Regist. 2016;81(96):31375-31473.

Olson-Kennedy J, Forcier M. Management of gender nonconformity in children and adolescents. [UpToDate Web site]. March 09 2023. Available at: https://www.uptodate.com/contents/management-of-gender-nonconformity-in-children-and-adolescents?source=search_result&search=gender dysphoria&selectedTitle=4~12 [via subscription only]. Accessed March 23, 2023.

Szafran A, Redett R, Burnett A. Penile transplantation: the US experience and institutional program set-up. Transl Androl Urol. 2018;7(4):639-664.

Tangpricha V, Safer JD. Transgender men: evaluation and management. [UpToDate Web site]. 12/02/2020. Available at: https://www.uptodate.com/contents/transgender-men-evaluation-and-management?source=search_result&search=gender dysphoria&selectedTitle=2~12 [via subscription only]. Accessed March 23, 2023.

Tangpricha V, Safer JD. Transgender women: evaluation and management. [UpToDate Web site]. 12/02/2021. Available at: https://www.uptodate.com/contents/transgender-women-evaluation-and-management?source=search_result&search=gender dysphoria&selectedTitle=1~12 [via subscription only]. Accessed March 23, 2023.

University of Massachusetts Amherst. The Stonewall Center: A Lesbian, Gay, Bisexual, Trans, Queer, Intersex, and Asexual (LGBTQIA+) Resource Center at the University of Massachusetts, Amherst. The Stonewall Center Web site. 2020. Available at: https://www.umass.edu/stonewall/. Accessed on November 23, 2023.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Histrelin acetate ( SUPPRELIN® LA) prescribing information. [FDA Web site]. Revised October 2011. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/022058s006lbl.pdf. Accessed March 23, 2023.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Histrelin implant (Vantas™) drug label. [FDA Web site]. November 2010. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/021732s013lbl.pdf. Accessed March 23, 2023.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Leuprolide acetate for depot suspension (LUPRON DEPOT) prescribing information. [FDA Web site]. Revised June 2014. Available at:
http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/020517s036_019732s041lbl.pdf. Accessed March 23, 2023.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Leuprolide acetate (ELIGARD® ) prescribing information. [FDA Web site]. Revised 2010. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/021343s019,021379s015,021488s016,021731s012lbl.pdf. Accessed March 23, 2023.

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Triptorelin pamoate for injectable suspension (TRELSTAR®) prescribing information. [FDA Web site]. Revised January 2011. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/020715s024,021288s021,022437s002lbl.pdf. Accessed March 23, 2023 .

US Food and Drug Administration (FDA). Center for Drug Evaluation and Research. Goserelin acetate implant (ZOLADEX®) prescribing information. [FDA Web site]. Revised June 2013. Available at: http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020578s034,020578s035lbl.pdf. Accessed March 23, 2023.

World Professional Association for Transgender Health, Inc. (WPATH). Clarification on medical necessity of treatment, sex reassignment, and insurance coverage in the U.S.A. WPATH. 2008;1-4. Also available on the WPATH Web site at: http://www.tgender.net/taw/WPATHMedNecofSRS.pdf. Accessed March 23, 2023.

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World Professional Association for Transgender Health (WPATH). Standards of Care for the Health of Transgender, and Gender Diverse People 8th version. 09/15 2022. Available at: https://www.wpath.org/soc8 . Assessed March 23, 2023.

Coding

CPT Procedure Code Number(s)

See Attachment B

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

F64.0 Transsexualism

F64.2 Gender identity disorder of childhood

F64.8 Other gender identity disorders

F64.9 Gender identity disorder, unspecified

Z87.890 Personal history of sex reassignment

HCPCS Level II Code Number(s)

MEDICALLY NECESSARY

C1789 Prosthesis, breast (implantable)

C1813 Prosthesis, penile, inflatable

C2622 Prosthesis, penile, noninflatable

D5919 facial prosthesis

D5925 facial augmentation implant prosthesis

D5929 facial prosthesis, replacement

D7996 implant-mandible for augmentation purposes (excluding alveolar ridge), by report

J1050 Injection, medroxyprogesterone acetate, 1 mg

J1071 Injection, testosterone cypionate, 1 mg

J1380 Injection, estradiol valerate, up to 10 mg

J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg

J1954 Injection, leuprolide acetate for depot suspension (cipla), 7.5 mg

J3121 Injection, testosterone enanthate, 1 mg

J3315 Injection, triptorelin pamoate, 3.75 mg

J3316 Injection, triptorelin, extended-release, 3.75 mg

J9202 Goserelin acetate implant, per 3.6 mg

J9217 Leuprolide acetate (for depot suspension), 7.5 mg

J9219 Leuprolide acetate implant, 65 mg

J9225 Histrelin implant (Vantas), 50 mg

J9226 Histrelin implant (Supprelin LA), 50 mg

L8000 Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type

L8001 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type

L8002 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type

L8010 Breast prosthesis, mastectomy sleeve

L8015 External breast prosthesis garment, with mastectomy form, post m astectomy

L8020 Breast prosthesis, mastectomy form

L8030 Breast prosthesis, silicone or equal, without integral adhesive

L8031 Breast prosthesis, silicone or equal, with integral adhesive

L8600 Implantable breast prosthesis, silicone or equal

S0189 Testosterone pellet, 75 mg

S9152 Speech therapy, re-evaluation

THE FOLLOWING CODE IS USED TO REPRESENT CHEST BINDERS, CHEST PADDING, AND GENITAL TUCKERS:
A9999 Miscellaneous DME supply or accessory, not otherwise specified

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 11.09.02o:

01/01/2024

This version of the policy will become effective 01/01/2024. This policy has been updated to communicate athe creation of policy coverage statements for gender affirming facial interventions, voice modification as medically necessary, and establishes medically necessary criteria for gender affirming chest surgery for individuals under age 18. Letter of recommendation requirements have been updated. Policy coverage statement regarding reversal surgery has been removed. Billing requirements addressing global intersex codes have been removed.

The following CPT codes have been added to this policy:

11920, 11921, 11922, 13151, 13152, 13153, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15260, 15261, 15769, 15770, 15819, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15829, 15838, 15839, 15876, 15977, 20670, 20680, 20690, 20692, 20693, 20694, 21025, 21085, 21087, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21235, 21247, 21270, 21280, 21282, 21345, 21346, 21347, 21348, 21421, 21422, 21423, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30520, 31570, 31750, 40510, 40520, 40525, 40527, 40650, 40652, 40654, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950, 69310, 69320, 92507, 92508, 92521, 92522, 92523, 92524

The following HCPCS codes have been added to this policy:
D5919, D5925, D5929, D7996, S9152

The following ICD-10 code has been deleted from this policy

F64.1 Dual role transvestism

Revisions From 11.09.02n:

05/08/2023

This version of the policy will become effective 05/08/2023. This policy has been updated to communicate additions to policy coverage statements within the policy section for chest surgery, genital surgery, and garments.

The following CPT codes have been added to this policy:

15240, 15241, 17380, 19318, 44145 , 53410, 53450 , 54406 , 54408, 54410, 54411, 54415, 54416, 54417, 56620, 56625, 56800, 56810, 57107, 57111, 58661, 17999, 55899, 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T.

The following HCPCS codes have been added to this policy:

L8000 Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type

L8001 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type

L8002 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type

L8010 Breast prosthesis, mastectomy sleeve

L8015 External breast prosthesis garment, with mastectomy form, post mastectomy

L8020 Breast prosthesis, mastectomy form

L8030 Breast prosthesis, silicone or equal, without integral adhesive

L8031 Breast prosthesis, silicone or equal, with integral adhesive
A9999 Miscellaneous DME supply or accessory, not otherwise specified

The following CPT codes have been removed to this policy:
19340, 19342

Revisions From 11.09.02m:

04/01/2023

This policy has been identified for the HCPCS code update, effective 04/01/2023.

The following HCPCS narrative has been revised to this policy: J1954.

Revisions From 11.09.02l:

01/01/2023

This policy has been identified for the HCPCS code update, effective 01/01/2023.

The following HCPCS narrative has been added in this policy: J1954.

Revisions From 11.09.02k:

01/01/2022

This policy has been identified for the CPT code update, effective 01/01/2022.

The following CPT narrative has been revised in this policy: 11981.

Revisions From 11.09.09j:

03/26/2021

This version of the policy will become effective 03/26/2021.

This policy has been updated to include gender affirming interventions for members belonging to fully-insured products in the state of New York.

Revisions From 11.09.02i:

01/04/2021

This version of the policy will become effective 01/04/2021.

This policy has been updated to communicate appropriate language with respect to gender affirming interventions. The policy title was changed:

FROM: Treatment of Gender Dysphoria
TO: Gender Affirming Interventions

The following CPT code has been deleted from this policy:

19324

The following CPT codes have been added to this policy:

15771, 15772

The following CPT codes have been revised in this policy:

11970, 11971, 19318, 19325, 19340, 19342, 19357, 19380

Revisions From 11.09.02h:

01/01/2020

Revisions From 11.09.02g:

04/15/2019

This version of the policy will become effective 04/15/2019.

The following criteria has been DELETED from the policy:

Under continuous hormone replacement therapy and puberty-suppressing hormones medically necessary policy statements

Recommended by a qualified professional provider who has consistently assessed the individual
One referral letter and/or chart documentation for hormone therapy is required from a qualified professional provider.
If the individual has significant medical or mental health concerns, they are reasonably well controlled.

Revisions From 11.09.02f:

01/01/2019

This policy has been identified for the HCPCS code update, effective 01/01/2019.

The following HCPCS code has been added to this policy: J3316.

The following HCPCS code has been deleted from this policy: C9016.

Revisions From 11.09.02e:

11/21/2018	This policy has been reviewed and reissued to communicate the Company's continuing position on Treatment of Gender Dysphoria.
01/01/2018	This policy has been identified for the HCPCS code update, effective 01/01/2018. The following HCPCS code has been added to this policy: C9016 Injection, triptorelin extended release, 3.75 mg

Revisions From 11.09.02d:

11/03/2017

This version of the policy will become effective 11/03/2017.

The intent of this policy remains unchanged, but the policy has been updated to further clarify the following:

Transgender language to include all gender nonconforming individuals
Potentially cosmetic or cosmetic procedures/therapies

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date:

1/1/2024

Version Issued Date:

1/2/2024

Version Reissued Date: