Due to the far-reaching and irreversible results of hormonal and/or surgical transformational measures, a step-wise approach to therapy for Gender Dysphoria which consists of accurate diagnosis and long-term treatment by a multi-disciplinary team including behavioral, medical and surgical specialists, is vital to the patient's best interest. As with any treatment involving psychiatric disorders, a thorough behavioral analysis by a qualified practitioner is needed.

After the diagnosis of gender dysphoria is made, the therapeutic approach to gender dysphoria usually includes three elements or phases (sometimes labeled triadic therapy): hormones of the desired gender, a real-life experience in the desired role, and surgery to change the genitalia and other sex characteristics. The most typical order, if all three elements are undertaken, is hormones followed by real-life experience and, finally surgery to change the genitalia and other sex characteristics. However, the diagnosis of gender dysphoria invites the consideration of a variety of therapeutic options, only one of which is the complete therapeutic triad. Clinicians have become increasingly aware that not all persons with gender dysphoria need or want all three elements of triadic therapy. Hormone therapy is administered under medical supervision and is important in the gender transition process by altering body hair, breast size, skin appearance and texture, body fat distribution, and the size and function of sex organs. Additionally, real-life experience is important to validate the individual's desire and ability to incorporate into their desired gender role within their social network and daily environment. This generally involves gender-specific appearance (garments, hairstyle, etc.), involvement in various activities in the desired gender role including work and academic settings, legal acquisition of a gender appropriate first name, and acknowledgement by others of their new gender role.

Gender affirming surgery is one treatment option for extreme cases of gender dysphoria. Gender affirming surgery is not a single procedure, but part of a complex process involving multiple medical, psychiatric, and surgical specialists working in conjunction with each other and the individual to achieve successful behavioral and medical outcomes. Before undertaking gender affirming surgery, important medical and psychological evaluations, medical therapies and behavioral trials are undertaken to confirm that surgery is the most appropriate treatment choice for the individual

Surgical treatment differs depending upon the original physical gender of the individual. For male-to-female patients, also known as transwomen, transgender women, or MTF, surgery involves removal of the testicles and penis and the creation of a pseudo vagina, clitoris, and labia. For female-to-male patients, also known as transmen, transgender men, or FTM, surgery involves removal of the uterus, ovaries, and vagina, and creation of a neophallus, and scrotum with scrotal prostheses. Additional surgical procedures may also be performed to improve the gender appropriate appearance of the individual. These include, but are not limited to, breast augmentation, liposuction, Adam's apple reduction, voice modification surgery (vocal cord shortening), rhinoplasty, facial reconstruction (facial bone reduction, jaw shortening, sculpturing), lip reduction, and chin implants.

Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)

I. Contract exclusions and/or limitations for gender affirming surgery, including related services such as medical counseling, psychological clearance for surgery in the absence of a need for behavioral health therapeutic services, and hormonal therapy, will determine the available benefit for gender affirming surgery.

II. For contracts that specify gender affirming surgery and related services as a covered benefit and have specific benefit applications and/or limitations for gender affirming surgery, such specific benefit applications and/or limitations will apply.

III. If coverage for gender affirming surgery is available, it is considered medically necessary when all of the criteria specified in each surgery subsection: III.A (for transgender men), III.B (for transgender women), III.C (both), or III.D (both) are met:

A. Criteria for mastectomy and creation of a male chest in female-to-male members:
1. Single letter of referral from a qualified mental health professional (see Policy Guidelines II, III), and
2. Persistent, well-documented gender dysphoria (see Policy Guidelines I); and
3. Capacity to make a fully informed decision and to give consent for treatment; and
4. Age of majority (18 years of age or older) - For members younger than 18 years of age, please see NOTE below; and
5. If significant medical or mental health concerns are present, they must be reasonably well controlled.

(NOTE: Hormone therapy is not a pre-requisite.

According to the WPATH Standards of Care 7th Edition, "Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression.")

B. Criteria for breast augmentation (implants/lipofilling) in male-to-female members:
1. Single letter of referral from a qualified mental health professional (see Policy Guidelines II, III), and
2. Persistent, well-documented gender dysphoria (see Policy Guidelines I); and
3. Capacity to make a fully informed decision and to give consent for treatment; and
4. Age of majority (18 years of age or older); and
5. If significant medical or mental health concerns are present, they must be reasonably well controlled.

(NOTE: Although not an explicit criterion, WPATH Standards of Care (Revision 7 p. 65) recommended that male-to-female members undergo feminizing hormone therapy (minimum of 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical/aesthetic results.)

C. Criteria for gonadectomy (hysterectomy and oophorectomy in female-to-male members and orchiectomy in male-to-female members):
1. Two letters of referral from qualified mental health professionals, one in a purely evaluative role (see Policy Guidelines II, III), and
2. Persistent, well-documented gender dysphoria (see Policy Guidelines I); and
3. Capacity to make a fully informed decision and to give consent for treatment; and
4. Age of majority (18 years of age or older); and
5. If significant medical or mental health concerns are present, they must be reasonably well controlled; and
6. Twelve (12) continuous months of hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones).

(NOTE: The aim of hormone therapy prior to gonadectomy is primarily to introduce a period of reversible estrogen or testosterone suppression, before the member undergoes irreversible surgical
intervention. WPATH Standards of Care, Revision 7, p. 66)

D. Criteria for genital reconstructive surgery (i.e., any combination of the following: vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and implantation of erection and/or testicular prosthesis in female-to-male members; penectomy, vaginoplasty, labiaplasty, vulvoplasty and clitoroplasty in male-to-female members).
1. Two letters of referral from qualified mental health professionals, one in a purely evaluative role (see Policy Guidelines II, III), and
2. Persistent, well-documented gender dysphoria (see Policy Guidelines I); and
3. Capacity to make a fully informed decision and to give consent for treatment; and
4. Age of majority (18 years of age or older); and
5. If significant medical or mental health concerns are present, they must be reasonably well controlled; and
6. Twelve (12) continuous months of hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones); and
7. Twelve (12) continuous months of living in a gender role that is congruent with their gender identity (real life experience).

(NOTE: Although not an explicit criterion, WPATH Standards of Care recommends that these members also have regular visits with a mental health or other medical professional.)

(NOTE: The above criteria are consistent with The World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People. (7th Version).¹⁰)

A. Male-to-female:
1. Breast/chest surgery
• augmentation mammoplasty (implants/lipofilling)
2. Genital surgery
• penectomy
• orchiectomy
• vaginoplasty
• clitoroplasty
• labiaplasty
• vulvoplasty

B. Female-to-male:
1. Breast/chest surgery
• mastectomy (subcutaneous)
• creation of a male chest
2. Genital surgery
• hysterectomy
• oophorectomy
• urethroplasty
• metoidioplasty
• phalloplasty
• vaginectomy
• scrotoplasty
• implantation of erection and/or testicular prosthesis

1. Revision surgery is medically necessary to correct complications of previous surgeries (e.g., granulation tissue, intravaginal scarring and complete vaginal stenosis for transgender women and penile/urethral strictures or fistulas in transgender men – not a comprehensive list).
2. Phalloplasty after metoidioplasty is medically necessary to alleviate issues after a metoidioplasty (inability to have penetrative intercourse, difficulty with voiding while standing).
3. Surgical repairs or revisions related to removal and replacement of breast, penile or testicular prostheses is medically necessary if related to complications (i.e., Baker IV contracture)
4. Revision surgery to alter body parts due to member dissatisfaction with the results of the original surgery (i.e., breast size/shape, penis size except as noted above) is cosmetic.

A. Procedures that assist in feminization (male-to-female):
• reduction thyroid chondroplasty (trachea shave)
• suction-assisted lipoplasty of the waist
• rhinoplasty
• facial feminization surgery / facial bone reduction / jaw shortening / sculpturing
• face-lift
• blepharoplasty
• voice modification surgery (vocal cord shortening)
• hair reconstruction / hair removal / electrolysis
• rhytidectomy
• gluteal augmentation (implants/lipofilling)
B. Procedures that assist in masculinization (female-to-male):
• voice modification surgery to obtain a deeper voice (rarely done per WPATH Standards of Care )
• liposuction (e.g., reduce fat in hips, thighs, and buttocks)
• pectoral implants
• chin implants
• lip reduction

A. 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 indicators:
1. 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)
2. 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)
3. a strong desire for the primary and/or secondary sex characteristics of the other gender
4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
6. 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)

1. The client's general identifying characteristics; and
2. Results of the client's psychosocial assessment, including any diagnoses; and
3. The duration of the mental health professional's relationship with the client, including the type of evaluation and therapy or counseling to date; and
4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient's request for surgery; and
5. A statement about the fact that informed consent has been obtained from the patient; and
6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

Note:
• One referral from a qualified mental health professional is needed for breast surgery (e.g., mastectomy).
• Two referrals – from qualified mental health professionals who have independently assessed the patient – are needed for genital surgery (i.e., hysterectomy/salpingo-oophorectomy, orchiectomy, genital reconstructive surgeries). If the first referral is from the patient’s psychotherapist, the second referral should be from a person who has only had an evaluative role with the patient. Two separate letters, or one letter signed by both (e.g., if practicing within the same clinic) may be sent. Each referral letter, however, is expected to cover the same topics in the areas outlined above.
  

1. A master’s degree or its equivalent in a clinical behavioral science field. This degree or a more advanced one should be granted by an institution accredited by the appropriate national or regional accrediting board. The mental health professional should also have documented credentials from the relevant licensing board or equivalent; and
2. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Diseases for diagnostic purposes; and
3. Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria; and
4. Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria.
5. Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.]

________________________________________________________________________________________

Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:
Gender Reassignment Surgery
Sex Reassignment Surgery
Gender Identity Disorder
Gender Dysphoria
Transgender Surgery
Transsexualism
Transmen
Transwomen

References:
1. The World Professional Association for Transgender Health (WPATH), formerly known as the Harry Benjamin International Gender Dysphoria Associaion, HBIGDA). Standards of Care for Gender Identity Disorders, Sixth Version. February, 2001. Available at: http://wpath.org/Documents2/socv6.pdf (last accessed 03/25/2010)

2. Hembree WC, Cohen-Kettenis P, et al; Endocrine Society. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guidelines. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54. Epub 2009 Jun 9. Available at: http://press.endocrine.org/doi/pdf/10.1210/jc.2009-0345 (current version as of 08/08/2015)

3. Day P. Tech Brief Series. Trans-gender Reassignment Surgery. New Zealand Health Technology Assessment (NZHTA) Report 2002;1(1).

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. (DSM-IV-TR). 2000.

5. Centers for Medicare and Medicaid Services (CMS). NCD for Transsexual Surgery (140.3). Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=140.3&ncd_version=1&basket=ncd%3A140%2E3%3A1%3ATranssexual+Surgery.

6. ECRI Institute’s Health Technology Assessment Information Service (HTAIS). Hotline Response: Sexual Reassignment for Gender Identity Disorders. Updated: 12/30/2009. (last accessed 04/05/2010)

7. Byne W, Bradley SJ, Eyler AE et al. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Arch Sex Behav. 2012 Aug;41(4):759-98.

8. American Psychiatric Association. Gender Dysphoria - explanation of replacing "disorder" with "dysphoria" in DSM 5. Available at: http://www.dsm5.org/documents/gender%20dysphoria%20fact%20sheet.pdf

9. CMS Manual System. Pub 100-03 Medicare National Coverage Determination (Transmittal 169). Subject: Invalidation of National Coverage Determination 140.3 - Transsexual Surgery. Effective date: May 30, 2014. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2014-Transmittals-Items/R169NCD.html

10. The World Professional Association for Transgender Health (WPATH). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People. 7th Version. 2012. Available at: http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf

11. Boas SR, Ascha M, Morrison SD, Massie JP, Nolan IT, Shen JK, Vyas KS, Satterwhite T. Outcomes and Predictors of Revision Labiaplasty and Clitoroplasty after Gender-Affirming Genital Surgery. Plast Reconstr Surg. 2019 Dec; 144(6)):1451-1461.

12. Veerman H, de Rooij FPW, Al-Tamimi M, Ronkes BL, Mullender MG, Bouman M, van der Sluis WB, Pigot GLS. Functional Outcomes and Urological Complications after Genital Gender Affirming Surgery with Urethral Lengthening in Transgender Men. J Urol. 2020 Feb 7: 101097JU0000000000000795. doi: 10.1097/JU.0000000000000795. [Epub ahead of print].

13. Al-Tamimi M, Pigot GL, van der Sluis WB, van de Grift TC, et al. The surgical Techniques and Outcomes of Secondary Phalloplasty after Metoidioplasty in Transgender Men: An International, Multi-Center Case Series. J Sex Med. 2019 Nov; 16(11):1849-1859.

14. Al-Tamimi M, Pigot GL, van der Sluis WB, van de Grift TC, Mullender MG, Groenman F, Bouman MB. Colpectomy Significantly Reduces the Risk of Urethral Fistula Formation after Urethral Lengthening in Transgender Men Undergoing Genital Gender Affirming Surgery. J Urol. 2018 Dec;200(6):1315-1322.

15. Djordjevic ML, Bizic MR, Duisin D, Bouman M-B, Buncamper M. Reversal Surgery in Regretful Male-to-Female Transsexuals After Sex Reassignment Surgery. J Sex Med. 2016 Jun;13(6):1000-7, siuL `0,1015/j.jsxm.2016.02.173. Epub 2-16 May 4.

16. Dhejne C, Öberg K, Aver S, Landén. An Analysis of All Applications for Sex Reassignment Surgery in Sweden, 1960-2010: Prevalence, Incidence, and Regrets. Arch Sex Behav. 2014 Nov;43(8):1535-45. Doi: 10.1007/s10508-014-0300-8. Epub 2014 May 29.

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

55970
55980