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:
DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents:
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
Male to Female
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
Non-Covered Procedures (due to being considered cosmetic in nature)
The process of gender reassignment does not include procedures to assist with fertility. Including, but not limited to:
*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].”
To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
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.