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Gender Affirming Interventions
11.09.02n

Policy

MEDICALLY NECESSARY

PUBERTY-SUPPRESSING HORMONES
Puberty-suppressing hormones (e.g., Supprelin LA® [histrelin acetate], Vantas® [histerlin 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 demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed), in accordance with criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition​ (DSM-5) or is gender diverse as defined in The World Professional Association for Transgender Health (WPATH)​: Standards of Care, 8th Version (SOC-8).
  • The individual has reached at least Tanner Stage 2 of development.
  • 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) for the treatment of gender dysphoria is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual has persistent, well-documented gender dysphoria diagnosed in accordance with the criteria established in the DSM-5 or is gender diverse as defined in SOC-8.
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, well-documented gender dysphoria in accordance with the criteria established in the DSM-5 or is gender diverse as defined in SOC-8.
  • Bilateral mastectomy is recommended by a qualified professional provider who has consistently monitored the individual up to the time of surgery.
    • One referral letter and/or chart documentation 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.
  • The individual is at least 18 years of age.
  • The individual, if required by the mental 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 mental health professional provider.
  • If the individual has significant medical or mental 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, well-documented gender dysphoria in accordance with the criteria established in the DSM-5 or is gender diverse as defined in SOC-8.
  • Bilateral reduction mammoplasty is recommended by a qualified professional provider who has consistently monitored the individual up to the time of surgery.
    • One referral letter and/or chart documentation 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.
  • The individual is at least 18 years of age.
  • The individual, if required by the mental 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 mental health professional provider.
  • If the individual has significant medical or mental 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, well-documented gender dysphoria in accordance with the criteria established in the DSM-5 or is gender diverse as defined in SOC-8​.
  • Breast augmentation is recommended by a qualified professional provider who has consistently monitored the individual up to the time of surgery.
    • One referral letter and/or chart documentation 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.
  • The individual is at least 18 years of age.
  • The individual, unless 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 mental 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 mental health professional provider.
  • If the individual has significant medical or mental health concerns, they are reasonably well controlled.
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, well-documented gender dysphoria in accordance with the criteria established in the DSM-5 or is gender diverse as defined in ​SOC-8.
  • Genital reconstructive surgery is recommended by two different qualified professional providers who have consistently monitored the individual up to the time of surgery.
    • If two mental health professional providers are working jointly with the individual, both mental health professional providers must sign one letter of recommendation and/or chart documentation 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 and/or chart documentation to the professional provider performing the genital surgery.
      • The letters and/or chart documentation must discuss the same topics in agreement with one another.
      • At least one of the letters and/or chart documentation must be an extensive report; the second letter may be a briefer summary.
  • The individual is at least 18 years of age.
  • The individual, unless 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 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.
  • If the individual has significant medical or mental 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​
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. 

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).

NOT MEDICALLY NECESSARY

Gender-reversal surgery postoperatively is considered not medically necessary and, therefore, not covered.

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
  • Blepharoplasty
  • 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
  • Facial masculinizing/feminizing surgeries (e.g., facial bone reduction)
  • Facial prosthesis (e.g., nasal, orbital)
  • Forehead reduction
  • 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)
  • Lip reduction/enhancement
  • Orthognathic procedures
  • Otoplasty
  • Pectoral implantation
  • Rhinoplasty
  • Rhytidectomy
  • Septoplasty
  • Tattooing (nontherapeutic)
  • Trachea shave/reduction thyroid chondroplasty
  • Voice therapy
  • Voice modification surgery (i.e., laryngoplasty, cricothyroid approximation)
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 mental 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 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 the 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 an individual 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

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.

BILLING GUIDELINES

Current Procedural Terminology (CPT) codes 55970 Intersex surgery; male to female or CPT 55980 Intersex surgery; female to male, are considered global procedure codes. These codes include distinct surgical procedures. Do not report individual procedure codes representing each component of a global procedure code.

CPT 55970 (Intersex surgery; male to female), includes the following procedures:
  • Orchiectomy
  • Penectomy
  • Vaginoplasty
  • Clitoroplasty
  • Labiaplasty
CPT 55980 (Intersex surgery; female to male), includes the following procedures:
  • Vaginectomy
  • Metoidioplasty
  • Phalloplasty
  • Urethroplasty
  • Scrotoplasty
  • Testicular prostheses implantation

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 (DSM-5) 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 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 diagnosed with gender dysphoria, 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® [histerlin 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 with gender dysphoria 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 demostrated individuals who undergo uterine transplantion have been able to sustain fetal growth and deliver a child. With the advent of the successful births via uterine transplantion, 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 occured in 2006. To date, the literature suggests a few case reports have ever been produced worldwide. As such, the evidence is insufficient to evaulate 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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​
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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.

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: https://www.wpath.org/media/cms/Documents/Web Transfer/SOC/Standards of Care V7 - 2011 WPATH.pdf. Accessed March 23, 2023.

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)

MEDICALLY NECESSARY

11960, 11970, 11971, 11980, 11981, 15240, 15241, 15771, 15772, 17380, 19303, 19318, 19325, 19350, 19357, 19380, 44145, 53410, 53430, 53450, 54125, 54400, 54401, 54405, 54406, 

54408, 54410, 54411, 54415, 54416, 54417, 54520, 54660, 54690, 55175, 55180, 55970, 55980, 56620, 56625, 56800, 56805, 56810, 57106, 57107, 57110, 57111, 57291, 57292, 57335, 

58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58661, 58720​


THE FOLLOWING CODE IS USED TO REPRESENT LASER HAIR REMOVAL/ELECTROLYSIS REQUIRED FOR SKIN PREPARATION FOR GENDER RECONSTRUCTIVE SURGERY 
17999


THE FOLLOWING CODE IS USED TO REPRESENT METOIODIOPLASTY AND/OR PHALLOPLASTY
55899


THE FOLLOWING CODE IS USED TO REPRESENT LABIAPLASTY
58999

 

EXPERIMENTAL/INVESTIGATIONAL 

GENITAL/REPRODUCTIVE ORGAN TRANSPLANTATION
0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T

 
THE FOLLOWING CODE IS USED TO REPRESENT PENILE TRANSPLANTATION
55899​

ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
F64.0 Transsexualism
F64.1 Dual role transvestism
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
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
 

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


​

Coding and Billing Requirements

Policy History

5/8/2023
5/24/2023
11.09.02
Medical Policy Bulletin
Commercial
No
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