Medical Policy: 07.01.57
Original Effective Date: March 2013
Reviewed: February 2015
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Gender dysphoria or gender identity disorder is a condition in which a person feels a strong and persistent identification with the opposite gender. Often this is accompanied by gender dysphoria, a severe sense of discomfort or distress caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth. Those with gender identity disorders frequently report a feeling of being born the wrong sex.
According to the American Psychiatric Association, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines gender dysphoria as a condition where a person’s gender at birth is contrary to the one they identify with. This definition replaces the criteria for gender identity disorder which will no longer be used in DSM-5. However, ICD-9 and ICD-10 codes continue to use the term gender identity disorder.
In 2010, the World Professional Association for Transgender Health (WPATH) released a statement noting that “the expression of gender characteristics, including identities that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon [that] should not be judged as inherently pathological or negative.” Accordingly, transsexual, transgender, and gender nonconforming persons are not intrinsically disordered. Rather, the distress of gender dysphoria, when present, is the matter that may be diagnosable and for which several therapeutic options are available. Therapeutic approaches include psychological interventions and gender reassignment therapy, including hormonal interventions that muscularize or feminize the body, and surgical interventions that change the genitalia and other sex characteristics. Gender identity disorders may manifest at childhood, adolescence, or adulthood.
The surgical procedures for male-to-female individuals, also known as “transwomen” may include orchiectomy, penectomy, vaginoplasty, clitoroplasty, and labioplasty. Techniques include penile skin inversion, pedicled colosigmoid transplant, and free skin grafts to line the neovagina. For female-to-male persons, also known as “transmen” surgery may include hysterectomy, ovariectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty, scrotoplasty, urethroplasty, placement of testicular prostheses, and phalloplasty. Prior to surgery, patients typically undergo hormone replacement therapy for a period of 12 continuous months. Biological females are treated with testosterone to increase muscle and bone mass, decrease breast size, increase clitoris size, increase facial and body hair, arrest menses, and deepen the voice. Biological males are treated with anti-androgens and estrogens to increase percentage of body fat compared to muscle mass, decrease body hair, decrease testicular size, decrease erectile function, and increase breast size.
Individuals diagnosed with gender dysphoria also must undertake real life experience living in the identity-congruent gender role. This provides sufficient opportunity for patients to experience and socially adjust in their desired role before undergoing irreversible surgery. During this experience, patients should present themselves consistently, on a day-to-day basis and across all life settings, in their desired gender role. This includes coming out to partners, family, friends and community members. Changing gender role can have profound personal and social consequences, and individuals must demonstrate an awareness of the challenges and the ability to function successfully in their gender role.
Individuals considering gender reassignment treatment will need to consider their reproductive health and make decisions concerning fertility prior to starting hormone therapy or undergoing surgery.
Prior Approval is required This is a group specific benefit. Prior approval is only necessary for those members seeking coverage under that benefit.
The following criteria are based on the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version, published by the World Professional Association for Transgender Health (WPATH).
Gender reassignment surgery may be considered medically necessary when ALL of the following criteria are met:
- the individual is age 18 years or older; AND
- has a confirmed diagnosis of gender identity disorder/gender dysphoria including all of the following:
- gender dysphoria resulting in clinically significant distress or impairment in social and occupational areas of functioning
- the disorder is not a symptom of another mental disorder or chromosomal abnormality
- the desire to live and be accepted as a member of the opposite sex, accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery or hormone treatment
- the transsexual identify has been persistently present for at least 2 years; AND
- for those without a medical contraindication to hormonal therapy, the individual has undergone a minimum of 12 continuous months of hormonal therapy as recommended by a mental health professional and supervised by a physician; AND
- documentation that the individual has completed a minimum of 12 months of successful continuous full-time real-life experience in their desired gender, across a wide span of life experiences and events that may occur throughout the year (i.e., holidays, vacations, season-specific school and/or work experience, family events)
- the documentation should include the start date of living in the desired gender role AND
- verification via medical or mental health professional communication with persons who have related to the individual in an identity-congruent gender role, or documentation of a legal name change; AND
- regular, active participation in a recognized gender identity treatment program; AND
- Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first letter is from the individual’s psychotherapist, the second referral should be from a person who has only had an evaluative role with the patient. The content of the referrals should include the following:
- the individual’s general identifying characteristics
- results of the psychosocial assessment, including any diagnoses
- the duration of the professional relationship with the individual, including the type of evaluation and therapy or counseling to date
- explanation that the criteria for surgery have been met, and a brief clinical rational for supporting the individuals request for surgery
- statement that the individual is capable of providing informed consent
*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 any comorbid psychiatric conditions. A single letter is sufficient if signed by two providers, one of whom has met the doctoral degree specifications, in addition to the other specifications listed.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- orchiectomy (simple) 54520, (laprascopic) 54690
- penectomy 54125
- vaginoplasty 57335
- clitoroplasty 56805
- labioplasty/vulvectomy 56625, 56630
- intersex surgery; male to female 55970
- construction of artificial vagina 57291,57292
hysterectomy 58150, 58262, 28291, 58552, 58554, 58571, 58573
Intersex surgery female to male 55980
placement of testicular prostheses 54660
The following procedures are considered cosmetic when used to improve the gender-specific appearance of an individual who has undergone or is planning to undergo gender reassignment surgery:
facial bone reconstruction 21125,21127,21137
face lift (rhytidectomy) 15824, 15825, 15826, 15828, 15829
neck tightening 15825, forehead 15824, cheek/chin 15828
collagen injections11950, 11951, 11952, 11954
reduction thyroid chondroplasty
liposuction 15876,15877,15878, 15879
voice modification surgery (unlisted larynx) 31599
voice therapy/voice lessons 92507
hair removal/hair transplant 15775, 15839, 17380
blepharoplasty 15822, 15823
breast augmentation, implants, silicone injections 19316, 19324,19325,19340
penile prosthesis 54400,54401,54405
removal of redundant skin 15830,15832,15833,15834, 15835, 15836, 15837, 15838, 15839, 15847
nipple/areola reconstruction 19350
- Center of Excellence for Transgender Health, University of California, San Francisco. 2011. Primary care protocol for transgender health care.
- De Cuypere G, T’Sjoen G, Beerten R et al. Sexual and physical health after sex reassignment surgery. Arch Sex Behav. 2005 Dec; 34(6): 679-90.
- Diamond M. Human intersexuality: Difference of disorder? Arch Sex Behav 2009 Apr; 38(2):172.
- Selvaggi G, Ceulemans P, De Cuypere G et al. Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plast Reconstr Surg. 2005; 116(6):135e-145e.
- American College of Obstetricians and Gynecologists (ACOG). Healthcare for transgender individuals. Committee Opinion. No 512. December 2011. Obstet Gynecol 2011; 118:1454-8.
- 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.
- 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 306-8.
- World Professional Association for Transgender Health (WPATH). Standards of Care for the Health of Transsexual, transgender, and Gender Nonconforming People. 7th version.
- American Psychiatric Association. (2013). Cautionary statement for forensic use of DSM-5. In Diagnostic and statistical manual of mental disorders (5th ed.). doi:10.1176/appi.books.9780890425596.744053
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Date Reason Action
March 2013 New policy
March 2014 Annual review Policy renewed
February 2015 Annual review Policy renewed
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.