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Medical Policy Bulletin

Title:Sex Reassignment Surgery (SRS) for Gender Identity Disorder (GID)

Policy #:11.09.02a



The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.


Intent
The intent of this policy is to communicate the coverage criteria and the Company's reimbursement position for sex reassignment surgery (SRS) for gender identity disorder (GID).

For information on policies related to this topic, refer to the Cross References section in this policy.

Description
GENDER IDENTITY DISORDER

Gender identity disorder (GID), also known as transsexualism, is a condition characterized by strong and persistent cross-gender identification accompanied by persistent gender dysphoria (Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition, Text Revision [DSM-IV-TR,2000]). Individuals with GID experience confusion in their biological gender during their childhood, adolescence, or adulthood. These individuals demonstrate clinically significant distress or impairment in social, occupational, or other important areas of functioning. GID is characterized by the desire to have the anatomy of the other sex, and the desire to be regarded by others as a member of the other sex. Individuals with GID may develop social isolation, emotional distress, poor self-image, depression, and anxiety. The diagnosis of GID is not made if the individual has a congruent physical intersex condition such as congenital adrenal hyperplasia. The current proposal by the American Psychiatric Association for the pending fifth edition on the DSM is to replace the term gender identity disorder with gender dysphoria, which refers to discomfort or distress that is caused by a discrepancy between an individual's gender identity and that individual's sex assigned at birth.

SEXUAL REASSIGNMENT THERAPY

GID cannot be treated by re-education or solely through medical intervention. There are therapeutic approaches to treat this disorder, including psychological interventions and sexual reassignment therapy (SRT). SRT, either as male-to-female transsexuals (transwomen) or as female-to-male transsexuals (transmen), consists of medical and surgical treatment that changes primary or secondary sex characteristics. Initially, the individual may go through the real-life experience in the desired role, followed by hormonal therapy and surgery to change the genitalia and other sex characteristics. The difference between hormone therapy and sex reassignment surgery (SRS) is that the surgery is considered an irreversible physical intervention.

In order to avoid difficulties with social integration and personal safety issues, it is important to change the individual's legal name and gender on identity documents prior to the surgical process.

The SRSs that may be performed for transwomen (male to female) include:
  • Orchiectomy: removal of testicles
  • Penectomy: removal of penis
  • Vaginoplasty: creation of vagina
  • Clitoroplasty: creation of clitoris
  • Labiaplasty: creation of labia

The SRSs that may be performed for transmen (female to male) include:
  • Mastectomy: removal of the breast
  • Reduction mammoplasty: reduction of breast size
  • Hysterectomy: removal of uterus
  • Salpingo-oophorectomy: removal of fallopian tubes and ovaries
  • Vaginectomy: removal of vagina
  • Metoidioplasty: creation of micro-penis, using the clitoris
  • Phalloplasty: creation of penis, with or without urethra
  • Urethroplasty: creation of urethra within the penis
  • Scrotoplasty: creation of scrotum
  • Testicular prostheses: implantation of artificial testes

Additionally, some surgeries that are proposed to improve gender-appropriate appearance include:
  • Liposuction: removal of fat
  • Rhinoplasty: reshaping of nose
  • Breast augmentation mammoplasty: enlargement of breasts
  • Rhytidectomy: face lift
  • Blepharoplasty: removal of redundant skin of the upper and/or lower eyelids and protruding periorbital fat
  • Hair removal/hair transplantation
  • Facial feminizing (eg, facial bone reduction)
  • Chin augmentation: reshaping or enhancing the size of the chin
  • Lip reduction/enhancement: decreasing/enlarging lip size
  • Cricothyroid approximation: voice modification that raises the vocal pitch by simulating contractions of the cricothyroid muscle with sutures
  • Trachea shave/reduction thyroid chondroplasty: reduction of the thyroid cartilage
  • Laryngoplasty: reshaping of laryngeal framework

Cosmetic services are provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone do not constitute improvement in physiologic function. An individual's sexual satisfaction after the surgery can vary depending on the success of the surgical reassignment technique and on the psychological stability of the individual.

Hormonal interventions and surgical procedures are not without risk for complications; therefore, individuals should undergo an extensive evaluation to explore psychological, family, and social issues prior to and post surgery. Readiness criteria for SRS includes the individual demonstrating progress in consolidating gender identity, and demonstrating progress in dealing with work, family, and interpersonal issues resulting in an improved state of mental health. In order to check the eligibility and readiness criteria for SRS, it is important for the individual to discuss the matter with a professional provider who is well-versed in the relevant medical and psychological aspects of GID. The mental health and medical professional providers responsible for the individual's treatment should work together in making a decision about the use of hormones during the months before the SRS. Transsexual individuals should regularly participate in psychotherapy in order to have smooth transitions and adjustments to the new social and physical outcomes.

TRANS-SPECIFIC CANCER SCREENING

Professional organizations such as American Cancer Society (ASC), American College of Obstetricians and Gynecologists (ACOG), and the US Preventive Services Task Force (USPSTF) provide recommended cancer screening guidelines to facilitate clinical decision-making by professional providers. Some cancer screening protocols are sex/gender-specific based on assumptions about the genitalia for a particular gender. There is little data on cancer risk specifically in transsexual individuals. There is difficulty in recommending sex/gender-specific screenings (eg, breast, cervix, ovaries, penis, prostate, testicles, uterus) for transsexual individuals because of their physiologic changes. For example, transmen who have not undergone a mastectomy have the same risks for breast cancer as non-transwomen. In transwomen, the prostate typically is not removed as part of genital surgery, so individuals who do not take feminizing hormones may be at the same risk for prostate cancer as non-transmen. Therefore, cancer screenings (eg, mammograms, prostate screenings) may be indicated based on the individual's original gender.

Policy
Coverage is subject to the terms, conditions, and limitations of the member's contract.
Note: Most Independence Blue Cross plans exclude coverage of sex reassignment surgery (gender reassignment surgery, transgender surgery) or any treatment of gender identity disorders.

COMMERCIAL PRODUCTS (NON-MEDICARE ADVANTAGE)

Any procedure or treatment designed to alter physical characteristics of the member to those of the opposite sex, and any other treatment or study related to sex transformation, is a standard benefit contract exclusion for all products of the Company and, therefore, is not eligible for reimbursement consideration, with the following exception:

When a benefit for sex reassignment surgery (SRS) exists, it is covered and eligible for reimbursement consideration by the Company according to the terms and conditions specified in the group benefit contract. When the benefit exists, SRS is considered medically necessary when all of the following criteria are met:
  • The individual is at least 18 years of age.
  • The individual has a documented Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition, Text Revision (DSM-IV-TR) diagnosis of gender identity disorder (GID) including all of the following:
    • The individual has a desire to live and be accepted as a member of the opposite sex, usually accompanied by the desire to make his or her body as congruent as possible with the preferred sex through hormone therapy and SRS.
    • The individual's transsexual identity has been present persistently for at least two years.
    • The GID is not a symptom of another mental disorder (eg, schizophrenia).
    • The GID causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The individual (unless medically contraindicated or the individual is otherwise unable or unwilling to take hormones) has used hormones of the desired gender continuously and responsibly (eg, screenings and follow-ups with the professional provider) for a 12-month period.
    • Hormone therapy is not a criterion for breast surgery (ie, the creation of a male chest) for transmen (female to male)
  • Requests for genital SRS (ie, vaginectomy, metoidioplasty, phalloplasty, scrotoplasty, testicular prostheses implantation for transmen [female to male] and penectomy, vaginoplasty, clitoroplasty, and labiaplasty for transwomen [male to female]) require that the individual has demonstrated successful, continuous full-time, real-life experience (ie, the act of fully adopting a new or evolving gender role or gender presentation in everyday life) for a 12-month period.
  • The individual has made changes to their legal documents (eg, name, gender).
  • The individual, if required by the mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider.
  • The individual's medical record must include all of the following documents to support the request for SRS:
    • Requests for instituting hormone therapy and/or referral for breast surgery (eg, mastectomy) must include the following:
      • One letter of recommendation must be written from the mental 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.
    • Requests for genital SRS must include either of the following documents:
      • If two mental health professional providers are working jointly with the individual, both mental health professional providers must sign one letter of recommendation to the professional provider performing the genital surgery.
      • If two mental health professional providers are working independently with the individual, each mental health professional provider must write a separate letter of recommendation to the professional provider performing the genital surgery.
          The letters must discuss the same topics in agreement with one another.
          At least one of the letters must be an extensive report; the second letter may be a briefer summary.
  • The individual has knowledge of all practical aspects (eg, cost, required lengths of hospitalizations, likely complications, postsurgical rehabilitation) of the SRS.

SURGICAL TREATMENTS FOR SEX REASSIGNMENT

When all of the above criteria are met AND a benefit for SRS exists, the following genital surgeries are covered for transwomen (male to female):
  • Orchiectomy
  • Penectomy
  • Vaginoplasty
  • Clitoroplasty
  • Labiaplasty

When all of the above criteria are met AND a benefit for SRS exists, the following genital/breast surgeries are covered for transmen (female to male):
  • Breast reconstruction (eg, mastectomy, reduction mammoplasty)
  • Hysterectomy
  • Salpingo-oophorectomy
  • Vaginectomy
  • Metoidioplasty
  • Phalloplasty
  • Urethroplasty
  • Scrotoplasty
  • Testicular prostheses implantation

The Company does not cover any sex reversal surgery (transman to woman or transwoman to man) post-operatively.

COSMETIC

The following procedures are considered cosmetic services. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration (this is not an all-inclusive list):
  • Liposuction
  • Rhinoplasty
  • Breast augmentation
  • Rhytidectomy
  • Blepharoplasty
  • Hair removal/hair transplantation
  • Facial feminizing (eg, facial bone reduction)
  • Chin augmentation
  • Lip reduction/enhancement
  • Cricothyroid approximation
  • Trachea shave/reduction thyroid chondroplasty
  • Laryngoplasty

MEDICARE ADVANTAGE PRODUCTS

As Original Medicare does not cover surgical procedures and associated therapies associated with SRS, these services are not covered for members enrolled in the Company’s Medicare Advantage products.

TRANS-SPECIFIC CANCER SCREENING

Subject to the terms and conditions of the applicable benefit contract, cancer screenings (eg, mammogram, routine gynecological examination, pap smear, and prostate-specific antigen [PSA]) are covered under the medical benefits of the Company’s products.

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 mental health professional provider's recommendation letter for hormone therapy or 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 mental 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 that fact that the mental health professional provider actually wrote the letter as described in this document

When two letters of recommendation are required and the first letter is from a person with a master's degree, the second letter should be from a psychiatrist or a PhD-level clinical psychologist, who can be expected to adequately evaluate co-morbid psychiatric conditions.

BENEFIT APPLICATION

Sex reassignment surgery (SRS) is not covered by the Company because it is a benefit contract exclusion for all of the Company's products. Therefore, it is not eligible for reimbursement consideration. However, when purchased as a group benefit, SRS is covered under the medical benefits of the Company's products when the criteria listed in this medical policy are met. Individual benefits must be verified, as coverage could vary between groups and products.

Subject to the terms and conditions of the applicable benefit contract, cancer screenings (eg, mammogram, routine gynecological examination, pap smear, and prostate-specific antigen [PSA]) are covered under the medical benefits of the Company’s products.

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

MEDICARE

This policy is consistent with Medicare’s coverage determination for SRS.

BILLING GUIDELINES

When reporting procedure code 55970 (Intersex surgery; male to female), the following staged procedures to remove portions of the male genitalia and form female external genitals are included:

  • The penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure.
  • The urethral opening is moved to a position similar to that of a female.
  • A vagina is made by dissecting and opening the perineum. This opening is lined using pedicle or split- thickness grafts.
  • Labia are created out of skin from the scrotum and adjacent tissue.
  • A stent or obturator is usually left in place in the newly created vagina for three weeks or longer.

When reporting procedure code 55980 (Intersex surgery; female to male), the following staged procedures to form a penis and scrotum using pedicle flap grafts and free skin grafts are included:
  • Portions of the clitoris are used, as well as the adjacent skin.
  • Prostheses are often placed in the penis to create a sexually functional organ.
  • Prosthetic testicles are implanted in the scrotum.
  • The vagina is closed or removed.

References

American College of Obstetricians and Gynecologists (ACOG). Healthcare for Transgender individuals. Committee Opinion. Obstet Gynecol. 2011:118:1454-8.

American College of Obstetricians and Gynecologists (ACOG). Health care for transgendered individuals. 2005. [ACOG Web site]. Available at: http://www.acog.org/About_ACOG/ACOG_Departments/Health_Care_for_Underserved_Women/Resources__and__Materials. [via subscription only]. Accessed January 28, 2013.

American Psychiatric Association. Sexual and gender identity disorders. In: First MB, ed. Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition - Text Revision (DSM-IV-TR). 4th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2000: 535-582.

American Psychological Association (APA) Task Force on Gender Identity and Gender Variance. 2009. Report of the Task Force on Gender Identity and Gender Variance.Washington, DC: American Psychological Association. Also available on the American Urological Association, Inc. Web site at: http://www.apa.org/pi/lgbt/resources/policy/gender-identity-report.pdf. Accessed January 28, 2013.

Ashbee O, Goldberg J. Trans people and cancer. [Vancouver Coastal Health Web site]. 02/2006 2. Available at:http://transhealth.vch.ca/resources/library/tcpdocs/consumer/medical-cancer.pdf. Accessed January 28, 2013.

Benet A and Melman A. Management of patients with gender dysphoria. In: Hellstrom W, eds. Male infertility and sexual dysfunction.New York, NY: Springer-Verlag New York, Inc; 1997: 563-571.

Bowman C, Goldberg J. Care of the patient undergoing sex reassignment surgery (SRS). [Vancouver Coastal Health Web site]. 01/2006. Available at: http://transhealth.vch.ca/resources/library/tcpdocs/guidelines-surgery.pdf. Accessed January 28, 2013.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 140.3: Transsexual surgery. [CMS Web site]. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=83&ncdver=1&bc=AgAAQAAAAAAA&. Accessed January 28, 2013.

Company Benefit Contracts.

ECRI Institute. Sexual reassignment for gender identity disorders. [ECRI Institute Web site]. 12/30/2009. Available at: https://members2.ecri.org/Components/Hotline/Pages/7310.aspx. [via subscription only]. Accessed January 28, 2013.

Gender Identity Research and Education Society (GIRES). A guide to lower surgery for trans men. [GIRES website]. Available at: http://www.gires.org.uk/assets/Support-Assets/lower-surgery.pdf. Accessed January 28, 2013.

Gibson B. Care of the child with the desire to change genders-part II: female-to-male transition. Pediatric Nursing.2010;36(2):112-118. Also available on the Medscape Web site at: http://www.medscape.com/viewarticle/722004. [Sign-in required.] Accessed January 28, 2013.

Gibson B, & Catlin AJ. Care of the child with the desire to change gender – Part I. Pediatric Nursing. 2010;36(1):53–59.

Hembree W, Cohen-Kettenis P, Delemarre-van de Waal H, et al. Endocrine treatment of transsexual persons: An endocrine society clinical practice guidelines. J Clin Endocrinol Metab.2009;94(9):3132-3154.

Medical treatment options for gender variant adults. [Gender Identity Research and Education Society Web site]. 2012. Available at: http://www.gires.org.uk/vmedtreatment.php. Accessed January 28, 2013.

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.wpath.org/Documents2/socv6.pdf. Accessed January 28, 2013.

The 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 January 28, 2013.

World Professional Association for Transgender Health (WPATH). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th version. 09/14/2011. Available at: http://www.wpath.org/publications_standards.cfm. Accessed January 28, 2013.

Vesely J. Gender transformation. [Cosmetic Plastic Surgery Web site]. 03/28/2007. Available at: http://www.cosmetic-plastic-surgery.info/procedures/treatment-of-transsexualism. Accessed January 28, 2013.

Zderic S. Sexual identity shifting paradigms for the management of ambiguous genitalia. AUA. 2002;21:162-167. Also available on the American Urological Association, Inc.Web site at: http://www.auanet.org/eforms/elearning/core/topics%5Cpediatrics%5Canomalies%5Cassets%5CUpdateSeries2002-Vol21-Lesson21.pdf. Accessed January 28, 2013.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



Cross References

Version Effective Date: 04/23/2013
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The Policy Bulletins on this web site were developed to assist Independence Blue Cross and its subsidiaries ("IBC") in administering the provisions of the respective benefit programs, and do not constitute a contract. If you are an IBC member, please refer to your specific benefit program for the terms, conditions, limitations and exclusions of your coverage. IBC does not provide health care services, medical advice or treatment, or guarantee the outcome or results of any medical services/treatments. The facility and professional providers are responsible for providing medical advice and treatment. Facility and professional providers are independent contractors and are not employees or agents of IBC. If you have a specific medical condition, please consult with your doctor. IBC reserves the right at any time to change or update its Policy Bulletins. ©2014 Independence Blue Cross. All Rights Reserved.  Current Procedural Terminology ©2014 American Medical Association. All Rights Reserved.


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