BlueCross BlueShield of Tennessee Medical Policy Manual

Gender Reassignment Surgery

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 Transsexual, Transgender, and Gender-Nonconforming People, Version 7 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: A person’s intrinsic sense of being male, female

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

Transsexual: Individuals who seek to change or who have changed their primary and/or secondary sex characteristics through feminizing or masculinizing medical interventions (hormones and/or surgery), typically accompanied by a permanent change in gender role.

Refer to the Gender Reassignment Precertification Request Form

POLICY

Gender reassignment 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 conjunction 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 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) 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 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 the other gender 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 12 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 12 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 12 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 12 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 12 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)



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, the express terms of the health plan will govern.

ADDITIONAL INFORMATION

According to the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7 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 Academy of Pediatrics / American College of Osteopathic Pediatricians. (2016, September). Supporting and caring for transgender children. Retrieved July 10, 2018 from http://hrc.im.

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.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-V™) (5th ed., pp. 451-459). American Psychiatric Publishing.

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.

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.

Edwards-Leeper, L., & Spack, N. P. (2012). Psychological evaluation and medical treatment of transgender youth in an interdisciplinary "Gender Management Service" (GeMS) in a major pediatric center. Journal of Homosexuality, 59 (3), 321-336. (Level 5 evidence)

Hewitt, J. K., Paul, C., Kasiannan, P., Grover, S. R., Newman, L. K., & Warne, G. L. (2012). Hormone treatment of gender identity disorder in a cohort of children and adolescents. Journal of the Australian Medical Association, 196 (9), 578-581. (Level 4 evidence)

Landén, M., Wålinder, J., Hambert, G., and Lundström, B. (1998, April). Factors predictive of regret in sex reassignment. Acta Psychiatrica Scandinavica, 94 (4), 284-289. Abstract retrieved September 13, 2017 from PubMed database.

Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLOS One, 6 (2), e16885. (Level 2 evidence)

Murad, M., Elamin, M., Garcia, M., Mullan, R., Murad, A., Erwin, P., and Montori, V. (2010). Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews. Abstract retrieved September 13, 2017 from PubMed database.

Rashid, Mamoon and Tamimy, Muhammad. (2013, May-August). Phalloplasty: the dream and the reality. Indian Journal of Plastic Surgery, 46 (2), 283-293. (Level 5 evidence)

Spack, N. P., Edwards-Leeper, L. Feldman, H. A., Leibowitz, S., Mandel, F., & Diamond, D. A. (2012). Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics, 129 (3), 418-425. (Level 4 evidence)

Winifred S. Hayes, Inc. Medical Technology Directory. (2014, May; last update search April 2018). Ancillary procedures and services for the treatment of gender dysphoria. Retrieved December 6, 2018 from www.Hayesinc.com / subscribers. (66 articles and or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2014, May; last update search August 2018). Hormone therapy for the treatment of gender dysphoria. Retrieved December 6, 2018 from www.Hayesinc.com / subscribers. (127 articles and or guidelines reviewed)

Winifred S. Hayes, Inc. Medical Technology Directory. (2018, August). Sex reassignment surgery for the treatment of gender dysphoria. Retrieved December 6, 2018 from www.Hayesinc.com/subscribers. (92 articles and or guidelines reviewed)

World Professional Association for Transgender Health (WPATH). (2011). Standards of Care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Retrieved September 13, 2013 from https://www.wpath.org/publications/soc.

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: 1/9/2020

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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.