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Date Printed: October 23, 2017: 02:16 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative 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.

02-55900-01

Original Effective Date: 11/15/11

Reviewed: 06/28/16

Revised: 10/01/16

Subject: Gender Reassignment Surgery

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

NOTE: Coverage for gender reassignment is subject to the member’s benefit terms, limitations and maximums. Refer to specific contract language regarding gender reassignment.

Gender reassignment surgery, also known as transsexual surgery, is the collection of several procedures designed to change the anatomy of individuals with gender identity disorders (GID).

Gender reassignment surgery, along with endocrine (hormone) therapy and real-life experience, is an accepted treatment of individuals diagnosed with transsexualism or profound GID.

The general goal of surgery, endocrine therapy, and psychotherapy for individuals diagnosed with GID is lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment. Prior to gender reassignment surgery, medical and psychological evaluations, medical therapies, and behavioral trials are recommended to confirm that surgery is an appropriate choice for the individual.

Gender reassignment surgery is intended to be a permanent change to an individual’s sexual identity and is not reversible. Therefore, a careful and accurate diagnosis is essential for treatment and can be made only as part of a long-term diagnostic process involving a multidisciplinary specialty approach that includes an extensive case history; gynecological, endocrinologic, and urological examination, and a clinical psychiatric/psychological examination. An individual’s self-assessment and request for sex reassignment cannot be viewed as reliable indicators of GID.

POSITION STATEMENT:

NOTE: Coverage for gender reassignment is subject to the member’s benefit terms, limitations and maximums. Refer to specific contract language regarding gender reassignment.

For purposes of this guideline, gender reassignment surgery may include any of the following procedures:

• Male-to-Female Procedures

- Clitoroplasty

- Labiaplasty

- Orchiectomy

- Penectomy

- Vaginoplasty

• Female-to-Male Procedures

- Hysterectomy

- Metoidioplasty

- Phalloplasty

- Salpingo-oophorectomy

- Scrotoplasty

- Testicular prostheses placement

- Urethroplasty

- Vaginectomy

- Breast reduction.

Gender reassignment surgery meets the definition of medically necessary when ALL of the following criteria are met:

  1. The individual has been diagnosed with the gender identity disorder (GID), including ALL of the following:

a. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; AND

b. The transsexual identity has been present persistently for 2 years or more; AND

c. The disorder is not a symptom of another mental disorder or a chromosomal abnormality; AND

d. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; AND

  1. For individuals without any medical contraindication, the individual has undergone at least 12 months of continuous hormonal therapy as recommended by a mental health professional and provided under the supervision of a physician; AND
  2. The individual has completed 12 months or more of successful continuous full time real-life experience in their new gender, without returning to their original gender, including ONE OR MORE of the following:

a. Maintain part- or full-time employment; OR

b. Function as a student in an academic setting; OR

c. Function in a community-based volunteer activity; AND

  1. The individual has obtained a legal gender-identity-appropriate name change; AND
  2. The individual has provided documentation to the treating therapist that persons other than the treating therapist know that the individual functions in the desired gender role; AND
  3. Regular participation in psychotherapy throughout the real-life experience as recommended by a treating medical or behavioral health practitioner; AND
  4. Demonstrates knowledge and understanding of the required length of hospitalizations, likely complications, and post surgical rehabilitation requirements of various surgical approaches; AND
  5. Demonstrates progress in consolidating one's gender identity, including demonstrating progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health (i.e., this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, suicidal tendencies); AND
  6. A letter from the individual's physician or mental health provider, who has treated the individual for a 18 months or more, documenting ALL of the following:

a. The individual's general identifying characteristics; AND

b. The initial and evolving gender, sexual, and other psychiatric diagnoses; AND

c. The duration of their professional relationship including the type of psychotherapy or evaluation that the individual underwent; AND

d. The eligibility criteria that have been met and the physician or mental health professional's rationale for surgery; AND

e. The degree to which the individual has followed the eligibility criteria to date and the likelihood of future compliance; AND

f. Whether the author of the report is part of a gender identity disorder treatment team; AND

  1. A letter from a second physician or mental health provider familiar with the individual's treatment and the psychological aspects of GID, corroborating the information provided in the first letter (see #10 above); AND
  2. When one of the letters indicated above is not from the treating surgeon, a letter from the surgeon confirming that that they have personally communicated with the treating mental health provider or physician, as well as the individual, and confirming that the individual meets the above criteria, understands the ramifications and possible complications of surgery, and that the surgeon feels that the individual is likely to benefit from surgery.

NOTE: At least one of the professionals submitting a letter must have a doctoral degree (Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D.) and be capable of adequately evaluating co-morbid psychiatric conditions. One letter is sufficient if signed by two providers, one of whom has met the doctoral degree specifications, in addition to the specifications set forth above.

Gender reassignment surgery does not meet the definition of medical necessity when one or more of the criteria listed above have not been met.

The following surgeries are considered cosmetic and do not meet the definition of medical necessity when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender reassignment surgery (this is not an all-inclusive list):

• Blepharoplasty

• Breast augmentation

• Face lift

• Facial bone reconstruction

• Hair removal/hairplasty

• Liposuction

• Reduction thyroid chondroplasty

• Rhinoplasty

• Voice modification surgery

BILLING/CODING INFORMATION:

CPT Coding:

55970

Intersex surgery; male to female

55980

Intersex surgery; female to male

Additionally, the following combinations of individual procedures may be billed separately:

19325

Mammoplasty, augmentation; with prosthetic implant

54125

Amputation of penis; complete

54520

Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach

54660

Insertion of testicular prosthesis

54690

Laparoscopy, surgical; orchiectomy

55180

Scrotoplasty; complicated

56625

Vulvectomy, simple; complete

56800

Plastic repair of introitus

56805

Clitoroplasty for intersex state

57110

Vaginectomy, complete removal of vaginal wall;

57291

Construction of artificial vagina; without graft

57292

Construction of artificial vagina; with graft

57295

Revision (including removal) of prosthetic vaginal graft; vaginal approach

57296

Revision (including removal) of prosthetic vaginal graft; open abdominal approach

57426

Revision (including removal) of prosthetic vaginal graft, laparoscopic approach

58150

Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);

58552

Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s)

58554

Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s)

58571

Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

58573

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Transsexual: individuals with an overwhelming desire to change anatomic sex because of their fixed conviction that they are members of the opposite sex.

RELATED GUIDELINES:

None

OTHER:

Other indexing terms relating to gender reassignment:

Gender change

Gender identity disorder

Intersex surgery

Sex change

Sex reassignment surgery

Sex reversal

Sex transformation surgery

Transgender surgery

Transsexual reassignment

Transsexual surgery

REFERENCES:

  1. Adelson SL, American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2012 Sep;51(9):957-74.
  2. American College of Obstetricians and Gynecologists (ACOG). Health care for transgendered individuals. 2005. Accessed 08/28/13.
  3. Asscheman H, Giltay EJ, Megens JA, de Ronde WP, van Trotsenburg MA, Gooren LJ. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol. 2011 Apr;164(4):635-42. Epub 2011 Jan 25.
  4. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Transsexual Surgery (140.3), (long standing NCD, effective date of this version not shown).
  5. Centers for Medicare & Medicaid Services (CMS). Pub. 100-03; Transmittal: 169; Change Request: 8825; June 27, 2014.
  6. Day P. Tech Brief Series. Trans-gender Reassignment Surgery. New Zealand Health Technology Assessment (NZHTA Report 2002); 1(1). Accessed 09/27/11.
  7. Dhejne C, Lichtenstein P, Boman M, Johansson AL, Långström N, Landén M. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLoS One. 2011 Feb 22;6(2):e16885.
  8. ECRI. Health Technology Forecast News Brief: Medicare to Consider Sex Reassignment Surgery on a Case-by-case Basis. Published 06/13/2014.
  9. Endocrine Society. Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline (J Clin Endocrinol Metab 94: 3132–3154, 2009).
  10. Gooren LJ. Clinical practice. Care of transsexual persons. N Engl J Med. 2011 Mar 31;364(13):1251-7.
  11. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer WJ 3rd, Spack NP, Tangpricha V, Montori VM; Endocrine Society. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54. Epub 2009 Jun 9.
  12. Lobato MI, Koff WJ, Crestana T, Chaves C, Salvador J, Petry AR, Silveira E, Henriques AA, Cervo F, Böhme ES, Massuda R. Using the Defensive Style Questionnaire to evaluate the impact of sex reassignment surgery on defensive mechanisms in transsexual patients. Rev Bras Psiquiatr. 2009 Dec;31(4):303-6. Epub 2009 Oct 16.
  13. Medraś M, Jóźków P. Transsexualism--diagnostic and therapeutic aspects. Endokrynol Pol. 2010 Jul-Aug;61(4):412-6.
  14. Meriggiola MC, Jannini EA, Lenzi A, Maggi M, Manieri C. Endocrine treatment of transsexual persons: an Endocrine Society Clinical Practice Guideline: commentary from a European perspective. Eur J Endocrinol. 2010 May;162(5):831-3. Epub 2010 Feb 11.
  15. National Guideline Clearinghouse. American Academy of Child and Adolescent Psychiatry (AACAP) – Practice parameter on gay, lesbian or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. Sept, 2012.
  16. National Guideline Clearinghouse. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. Aug, 2010.
  17. Wierckx K, Van Caenegem E, Pennings G, Elaut E, Dedecker D, Van de Peer F, Weyers S, De Sutter P, T'Sjoen G. Reproductive wish in transsexual men. Hum Reprod. 2012 Feb;27(2):483-7. doi: 10.1093/humrep/der406. Epub 2011 Nov 28.
  18. Wierckx K, Elaut E, Van Caenegem E, Van De Peer F, Dedecker D, Van Houdenhove E, T'Sjoen G. Sexual desire in female-to-male transsexual persons: exploration of the role of testosterone administration. Eur J Endocrinol. 2011 Aug;165(2):331-7. doi: 10.1530/EJE-11-0250. Epub 2011 May 20.
  19. World Professional Association for Transgender Health (WPATH) (formerly The Harry Benjamin International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders, Sixth Version, (02/01)
  20. World Professional Association for Transgender Health (WPATH) Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide - Medical Necessity Statement; June 17, 2008.
  21. World Professional Association for Transgender Health (WPATH). Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th version. 2011. Accessed 09/10/14.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 06/28/16.

GUIDELINE UPDATE INFORMATION:

11/15/11

New Medical Coverage Guideline.

10/15/12

Annual review; position statement unchanged; references updated.

11/15/13

Annual review; position statement unchanged; Program Exceptions section updated; references updated.

11/15/14

Annual review; position statement unchanged; Program Exceptions section updated; references updated.

07/15/16

Revision; guideline title and position statements section updated.

10/01/16

Revision; coding section updated.

Date Printed: October 23, 2017: 02:16 AM