Medical Policy: 07.01.57
Original Effective Date: March 2013
Reviewed: February 2016
Revised: February 2016
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.
The benefit of gender reassignment surgery is only available to select employee groups that have chosen to add this to their benefit package.
Biological sex is assigned at birth, depending on the appearance of the genitals. Gender identity is the gender that a person "identifies" with or feels themselves to be.
While biological sex and gender identity are the same for most people, this is not the case for everyone. For example, some people may have the anatomy of a man, but identify themselves as a woman, while others may not feel they are definitively either male or female.
This mismatch between sex and gender identity can lead to distressing and uncomfortable feelings that are called gender dysphoria. Gender dysphoria is a recognized medical condition, for which treatment is sometimes appropriate. The condition is also sometimes known as gender identity disorder (GID), gender incongruence or transgenderism.
Some people with gender dysphoria have a strong and persistent desire to live according to their gender identity, rather than their biological sex. These people are sometimes called transsexual or trans people. Some trans people have treatment to make their physical appearance more consistent with their gender identity.
Gender dysphoria is not the same as transvestism or cross-dressing and is not related to sexual orientation. People with the condition may identify as straight, gay, lesbian, bisexual or asexual, and this may change with treatment. 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.
Treatment for gender dysphoria aims to help reduce or remove the distressing feelings of a mismatch between biological sex and gender identity. This can mean different things for different people. For some people, it can mean dressing and living as their preferred gender. For others, it can mean taking hormones or having surgery to change their physical appearance. Many trans people have treatment to change their body permanently, so that they are more consistent with their gender identity, and the vast majority are satisfied with the eventual results.
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 at least 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, if chosen by the employer.
Prior approval is only necessary for those members seeking coverage under that benefit.
Qualifications for all gender reassignment treatments:
- Single letter of referral from a qualified mental health professional; and
- Persistent, well-documented gender dysphoria (per DSM V criteria below); and
- Capacity to make a fully informed decision and to consent for treatment; and
- 18 years of age or older; and
- If significant medical or mental health concerns are present, they must be reasonably well controlled.
DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents:
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:
- 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)
- 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)
- A strong desire for the primary and/or secondary sex characteristics of the other gender
- A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
- A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
- 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)
B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The treatment for Gender Dysphoria involves some combination of hormone therapy, sex reassignment surgery and/or Real Life Experience (living for a period of time in accordance with your gender identity). Each patient must be evaluated on a case-by-case basis, with expert medical judgment required for both reaching a diagnosis and determining a course of treatment. There is no set formula for gender transition.
Additional qualifications for Breast Surgery
Male to Female (breast augmentation)
Female to Male (breast mastectomy)
Genital Reassignment Surgery
Additional qualifications prior to genital reconstruction surgery
- Living 12 months of continuous, full time real life experience in the desired gender
- 12 months of continuous hormone therapy (unless contraindications exists)
- Two referral letters from qualified mental health professionals. The professional should include the physician responsible for endocrine transition therapy and the mental health professional providing current treatment.
Male to Female
- vaginoplasty ( including colovaginoplasty, penectomy, labiaplasty, clitoroplasty, vulvoplasty, penile skin inversion, repair of introitus, construction of vagina with graft, coloproctostomy)
Colovaginoplasty is best viewed as two separate operations taking place simultaneously. The first, a general surgery team, performs laparotomy on the abdomen, harvesting a 15 to 20 centimeter colon interposition flap. During this time, the reassignment team performs many of the duties also done in a penile inversion, such as removal of the gonads, and corpora cavernosae. (if either are present) At this point, the general surgery team will internally hand off the colon segment to the reassignment team and secure it in place in the perineal body. And finally, the urethra is put in place, external genitalia are formed, and the patient is prepared for recovery.
Female to Male
vaginectomy (including colpectomy, metoidioplasty, phalloplasty, urethroplasty, urethromeatoplasty)
Non-Covered Procedures (due to being considered cosmetic in nature)
- body contouring (waist liposuction)
- brow lift
- calf implants
- cheek/malar implants
- chin/nose implants
- collagen injections
- drugs for hair loss or growth
- drugs for sexual performance after genital reconstruction
- drugs for other cosmetic purposes
- face/forehead lift
- facial bone reduction
- hair removal/hair transplantation
- jaw shortening/sculpturing/facial bone reduction
- lip reduction/enhancement
- mastopexy/breast lift
- neck tightening
- nipple/areola reconstruction
- nose implants
- pectoral implants
- penile prosthesis (noninflatable /inflatable)
- removal of redundant skin
- replacement of tissue expander with permanent prosthesis testicular insertion
- resizing of the nipple-areola complex
- skin resurfacing (e.g., dermabrasion, chemical peels)
- surgical correction of hydraulic abnormality of inflatable (multi-component) prosthesis including pump and/or cylinders and/or reservoir
- testicular expanders
- testicular prostheses
- thyroid chondroplasty
- trachea shave/reduction thyroid chondroplasty
- voice modification surgery
- voice therapy
The process of gender reassignment does not include procedures to assist with fertility. Including, but not limited to:
- Storage and thawing of reproductive tissue (ie, ovaries, testicular tissue)
- Procurement and cryopreservation or storage of embryos, sperm or oocytes
*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.
The AMA passed a resolution in 2008 recognizing “an established body of medical research” that “demonstrates the effectiveness and medical necessity of mental health care, hormone therapy, and sex reassignment surgery as forms of therapeutic treatment for many patients diagnosed with [Gender Dysphoria].”
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.
- Center of Excellence for Transgender Health, University of California, San Francisco. 2011. Primary care protocol for transgender health care. Available at: http:// transhealth.ucsf.edu/trans?page=ab-00-00. Accessed August 14, 2012.
- 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.
- 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.
- Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, version 7 2012; World Professional Association for Transgender Health (WPATH)
- Trans - a practical guide for the NHS; Dept of Health, October 2008
- Technical Note - Measuring gender identity; Equality and Human Rights Commission survey, 2012
- Guidance for GPs, other clinicians and health professionals on the care of gender variant people; NHS, 2008
- Gender dysphoria services. A guide for general practitioners and other healthcare staff; NHS, 2012
- Meriggiola MC, Berra M; Safety of hormonal treatment in transgenders. Curr Opin Endocrinol Diabetes Obes. 2013 Dec;20(6):565-9. doi: 10.1097/01.med.0000436187.95351.a9.
- Hembree WC; Management of juvenile gender dysphoria. Curr Opin Endocrinol Diabetes Obes. 2013 Dec;20(6):559-64. doi: 10.1097/01.med.0000436193.33470.1f.
- Dhejne C, Lichtenstein P, Boman M, et al; Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLoS One. 2011 Feb 22;6(2):e16885. doi: 10.1371/journal.pone.0016885.
February 2016 - Annual Review, Policy Revised
February 2015 - Annual Review, Policy Renewed
March 2014 - Annual Review, Policy Renewed
March 2013, New Policy
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.