S-184-014

Topic:

Gender Affirmation Surgery (Previously Gender Reassignment Surgery)

Section:

Surgery

Effective Date:

Issued Date:

July 18, 2022

Last Revision Date:

July 2022

Annual Review:

July 2022

Gender affirmation surgery, consists of medical and surgical treatments that change primary sex characteristics for individuals diagnosed with gender dysphoria. The treatment for gender dysphoria is for the individual to align their physical primary and/or secondary sex traits with their gender identity to the extent that alleviates the symptoms.

Policy Position

Delaware Mandate:

18 Delaware Code Section 2304(22)): Prohibits discrimination by an insurer on the basis of an individual’s gender identity. Gender Identity is defined as an individual’s gender appearance, expression or behavior regardless of the individual’s assigned sex at birth. Delaware Department of Insurance Bulletin 86, effective March 23, 2016, prohibits the denial, exclusion or limitation of coverage for medically necessary services, at determined by a medical provider in consultation with the individual, and based on the individual’s gender identity if the service would be covered for another individual under such contract of insurance. Coverage exclusions related to medically necessary surgeries or treatments related to gender transition or related services for gender dysphoria or gender identity disorder is a violation of 18 Delaware Code Section 2304. Determinations of medical necessity, eligibility and prior authorization requirements for diagnoses related to an insured’s gender identity must be based on current medical standards established by nationally recognized transgender health medical experts.

Gender affirmation surgery may be considered medically necessary when ALL of the following are met:

• The individual is greater than or equal to 18 years of age; and
• The individual has the capacity to make a fully informed decision and to consent for treatment; and
• The individual has been diagnosed with the gender dysphoria, including ALL of the following:
  • The desire to live and be accepted as a member of another gender, usually accompanied by the wish to make their body as congruent as possible with the identified gender through surgery and hormone treatment; and
  • The individual's identity has been present persistently for at least six (6) months; and
  • The dysphoria is not a symptom of another mental disorder; and
  • Any significant medical or mental health diagnosis that is present including severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder) which may require psychotropic medications and/or psychotherapy, and including Substance Use Disorder, must be reasonably well controlled before surgery is contemplated; and
  • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The individual is under the care of physicians and/or mental health providers who are able to document ALL of the following conditions:
• For chest surgery (mastectomy and chest reconstruction)
  • Initiation of hormonal therapy (unless medically contraindicated or individual is unable or unwilling to take hormones); and
  • One (1) referral from a qualified mental health professional with written documentation submitted to the physician performing the breast surgery; and
• For hysterectomy and salpingo-oopherectomy, orchiectomy:
  • Documentation of at least 12 months of continuous hormonal sex reassignment therapy, (unless medically contraindicated or individual is unable or unwilling to take hormones); and
• For vaginoplasty, phalloplasty, metoidioplasty:
  • The individual has successfully lived and worked within the identified gender role full-time for at least 12 months (real life experience) without returning to the original gender (unless doing so would jeopardize the individual's safety); and
  • Documentation of at least 12 months of continuous hormonal therapy, (unless medically contraindicated or individual is unable or unwilling to take hormones); and
  • Separate evaluation by the physician performing the genital surgery.; and
  • The individual must complete a psychological evaluation performed by a licensed mental health care professional and be recommended for surgery. The individual's medical record documentation should indicate that all psychosocial issues have been identified and addressed and the individual expresses understanding 7ofthe permanency of surgical intervention.

Surgical Services for Adolescents

Individuals < 18 years of age will be considered on a case-by-case basis for breast reduction/augmentation for gender dysphoria. Supporting documentation should include:

• The individual has been assessed for any co-existing mental health concerns; and
• The individual has adequate support in place; and
• The individual meets the additional requirements above.

When ALL of the above criteria are met, the following surgeries may be considered medically necessary:

• Breast augmentation (including nipple/areolar reconstruction)
• Chest masculinization (including nipple/areolar reconstruction)
• Orchiectomy
• Clitoroplasty
• Colovaginoplasty
• Labiaplasty
• Orchiectomy
• Penectomy
• Vaginoplasty
• Colpectomy/Vaginectomy
• Hysterectomy
• Metoidioplasty
• Penile prosthesis
• Phalloplasty
• Salpingo-oophorectomy
• Scrotoplasty
• Testicular prosthesis implantation
• Urethroplasty

Electrolysis/ Laser hair removal may be considered medically necessary for the removal of hair on a skin graft donor site prior to its use in genital gender affirmation surgery.

Note: Penile prosthesis surgery is typically performed at stage two (2) or three (3) of a multi-stage phalloplasty (a minimum of nine (9) months following stage one (1)).

Note: Although not a requirement, it is recommended that individuals undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

Surgical Revisions

Reconstructive surgery, following gender affirmation surgery may be considered medically necessary when it is performed for ANY of the following reasons:

• Correct complications resulting from the initial surgery, or
• Correct a medical condition that resulted from the initial surgery that requires intervention, or
• Correct functional impairment resulting from initial surgery.

Reconstructive surgery following gender affirmation surgery to reverse natural signs of aging or if the patient is not satisfied with the aesthetic result is considered cosmetic and is not medically necessary.

The following services are considered cosmetic and not covered, unless they are determined medically necessary to treat the member’s condition based on scientific, medical literature and standards recognized by transgender health medical experts and are not primarily for aesthetic purposes or to reverse natural signs of aging (this is not an all-inclusive list):

• Abdominoplasty
• Blepharoplasty/brow reduction/brow lift
• Chin augmentation/reshaping
• Cheek, chin and nose implants
• Cricothyroid approximation
• Collagen injections
• Face lift (e.g., face, brow, etc.)
• Facial bone reconstruction for feminization or masculinization
• Facial feminization surgery
• Forehead lift/Forehead Augmentation
• Gluteal augmentation Hip
• Hair augmentation/reconstruction/ hairplasty
• Hair removal or electrolysis (unless for preparation of graft donor site).
• Laryngoplasty
• Liposuction/body contouring/lipofilling
• Lip reduction/enhancement
• Jaw/mandibular reduction/augmentation/sculpturing
• Implants for body contouring other than breasts (e.g., calf)
• Pectoral Implants
• Rhinoplasty including nose implants
• Skin resurfacing
• Tracheal shaving/reduction thyroid chondroplasty/thyroid cartilage reduction
• Voice modification surgery
• Voice retraining
• Vulvoplasty

Preventive Medicine GRS

Please refer to the member specific benefit plan for screenings (e.g., mammogram, routine gynecological examination, pap smear).

Preventive services are subject to the terms of the member’s individual or group customer benefit

Related Policies

Refer to Medical Policy S-28 Cosmetic Surgery vs. Reconstructive Surgery for additional information.

Refer to Medical Policy G-9, Diagnosis and Treatment of Male Sexual Dysfunction, for additional information.

Place of Service: Inpatient/Outpatient

Gender Affirmation Surgery is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Links

• Link to Provider Resource Center for the Medical Policy Update
09/2018 Revised criteria for Gender Reassignment Surgery

• Link to References

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.