Section: | Surgery |
Number: | S-184 |
Topic: | Gender Reassignment Surgery |
Effective Date: | March 5, 2012 |
Issued Date: | March 5, 2012 |
Date Last Reviewed: | 11/2011 |
Coverage for gender reassignment surgery (GRS) is determined according to individual or group customer benefits. When a covered benefit for gender reassignment surgery (55970, 55980) exists, it is considered medically necessary when all of the following criteria are met:
Surgical Treatment for Gender Reassignment
When a covered benefit for gender reassignment surgery exists and all of the above criteria are met, the following breast and genital surgeries are medically necessary for transmen (female to male):
Cosmetic Procedures
See Medical Policy Bulletin S-28 for general information on cosmetic surgery vs. reconstructive surgery. Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy. Examples include:
Services not meeting the medical necessity guidelines on this policy will be denied as not medically necessary. A participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider’s records. 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 circumstances may warrant individual consideration, based on review of applicable medical records. Description Gender Identity Disorder Gender Reassignment Surgery Transmen assume male gender identities or strive to present in more male gender roles. Gender reassignment surgery from female to male (FTM) includes surgical procedures that reshape a female body into the appearance of a male body. According to the World Professional Association for Transgender Health Standards of Care (WPATH SOC) guidelines, procedures often performed as part of gender reassignment surgery of FTM include mastectomy, hysterectomy, salpingo-oophorectomy, colpectomy (i.e., removal of the vagina, vaginectomy) and metoidioplasty (i.e., clitoral tissue is released and moved forward to approximate the position of a penis, skin from the labia minora is used to create a penis), urethroplasty, scrotoplasty and placement of testicular prosthesis ( i.e., the labia majora is dissected forming cavities allowing for placement of testicular implants) and phalloplasty (i.e., skin tissue graft is used to form a penis). The objectives of phalloplasty may include standing micturation, improved sexual sensation and function and/or appearance. Transwomen strive for a female identity. Gender reassignment surgery from male to female (MTF) includes procedures that shape a male body into the appearance of and, to the maximum extent possible, the function of a female body. Procedures often performed as part of gender reassignment surgery of MTF according to WPATH SOC include orchiectomy, vaginoplasty, penectomy, and labiaplasty. Surgical techniques vary but may include penile inversion to create a vagina and clitoris or creation of a vagina from the sigmoid colon (i.e., colovaginoplasty). The objectives of vaginoplasty include improved sexual sensation and function and appearance. Breast augmentation may be considered when 18 months of hormone treatment fails to result in breast enlargement that is sufficient for the individual’s comfort in the female gender role. 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. 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 improvements 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 GRS 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 GRS, 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 GRS. Transsexual individuals should regularly participate in psychotherapy in order to have smooth transitions and adjustments to the new social and physical outcomes. |
|
12/2011, Gender reassignment surgery coverage criteria defined |
Sutcliffe PA, Dixon S, Akehurst RL, et al. Evaluation of surgical procedures for sex reassignment: A systematic review. J Plast Reconstr Aesthet Surg. 2009 Mar;62(3):294-306;discussion 306-308. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54. Meriggiola MC, Jannini EA, Lenzi A, et al. Endocrine treatment of transsexual persons: An Endocrine Society Clinical Practice Guideline: Commentary from a European perspective. Eur J Endocrinol. 2010;162(5):831-833. Tønseth KA, Bjark T, Kratz G, et al. Sex reassignment surgery in transsexuals. Tidsskr Nor Laegeforen. 2010 Feb 25;130(4):376-379. World Professional Association for Transgender Health. The Harry Benjamin International Gender Dysphoria Association. Standards of Care for Gender Identity Disorders. 6th version. 2001 Feb. Accessed November 2011. Available at: http://www.wpath.org/documents2/socv6.pdf. |
[Version 001 of S-184] |