Medical Policy Manual Approved Revised Policy: Do Not Implement Until 4/2/19

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1 Plicy Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 4/2/19 Gender Reassignment Surgery DESCRIPTION Gender reassignment surgery is a term used t describe multiple medical and/r surgical treatments related t alleviating gender dysphria. Gender is a term that refers t the psychlgical and cultural characteristics assciated with bilgical sex. It is a psychlgical cncept and scilgical term, nt a bilgical ne. Gender identity refers t an individual s awareness f being male r female and is smetimes referred t as an individual s experienced gender. Gender dysphria refers t discmfrt r distress that is caused by a discrepancy between a persn s gender identity and that persn s bilgy. Accrding t the Standards f Care fr the Health f Transsexual, Transgender, and Gender-Nncnfrming Peple, Versin 7 prvided by the Wrld Prfessinal Assciatin fr Transgender Health treatment ptins fr gender dysphria may include: Psychtherapy (individual, cuple, family, r grup) fr purpses such as explring gender identity, rle, and expressin; addressing the negative impact f gender dysphria and stigma n mental health; alleviating internalized transphbia; enhancing scial and peer supprt; imprving bdy image; r prmting resilience. Changes in gender expressin and rle, which may invlve living part time r full time in anther gender rle, cnsistent with ne s gender identity; Hrmne therapy t feminize r masculinize the bdy; Surgery t change primary and/r secndary sex characteristics (e.g., breasts/chest, external and/r internal genitalia, facial features, bdy cnturing); Definitins: Gender identity: A persn s intrinsic sense f being male, female Gender-nncnfrming: Individual whse gender identity, rle, r expressin differs frm what is nrmative fr their bilgy in a given culture and histrical perid Transgender: Individuals wh crss r transcend culturally defined categries f gender. The gender identity f transgender peple differs t varying degrees frm their bilgic sex Transsexual: Individuals wh seek t change r wh have changed their primary and/r secndary sex characteristics thrugh feminizing r masculinizing medical interventins (hrmnes and/r surgery), typically accmpanied by a permanent change in gender rle. POLICY Gender reassignment surgery is cnsidered medically necessary if the medical apprpriateness criteria are met. (See Medical Apprpriateness belw.) Other prcedures, including but nt limited t the fllwing, are cnsidered csmetic when perfrmed in cnjunctin with gender reassignment surgery: abdminplasty blepharplasty subsequent breast enlargement prcedures, including augmentatin mammplasty, implants, and silicne injectins f the breast brw lift This dcument has been classified as public infrmatin.

2 Plicy Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 4/2/19 calf implants cheek/malar implants chin/nse implants cllagen injectins electrlysis face/frehead lift hair remval/hair transplantatin jaw shrtening/sculpturing/facial bne reductin laryngplasty lip reductin/enhancement lipsuctin mastpexy neck tightening pectral implants remval f redundant skin replacement f tissue expander with permanent prsthesis testicular insertin rhinplasty subsequent phallplasty (i.e. surgery t insert erectile prsthesis r imprve appearance) skin resurfacing (e.g., dermabrasin, chemical peels) surgical crrectin f hydraulic abnrmality f inflatable (multi-cmpnent) prsthesis including pump and/r cylinders and/r reservir testicular expanders trachea shave/reductin thyrid chndrplasty vice mdificatin surgery vice therapy/vice lessns MEDICAL APPROPRIATENESS Gender reassignment surgery r gender reassignment surgery reversal is cnsidered medically apprpriate if ALL f the fllwing are met: Individual is 18 years r lder Individual has the capacity t make a fully infrmed cnsent t treatment Any significant medical cncerns are well cntrlled (e.g. hypertensin, diabetes, crnary artery disease) Any significant mental health cncerns are well cntrlled (e.g. anxiety, depressin, cnduct disrder, substance abuse, dissciative identity disrders, brderline persnality disrder) Dcumentatin shws persistent and well dcumented gender dysphria as evidenced by ALL f the fllwing (DSM-V definitin): The cnditin is assciated with clinically significant distress r impairment in scial, ccupatinal, r ther imprtant areas f functining. A marked incngruence between ne s experienced/expressed gender and assigned gender, f at least 6 mnths duratin, as manifested by TWO OR MORE f the fllwing: A marked incngruence between ne s experienced/expressed gender and primary and/r secndary sex characteristics A strng desire t be rid f ne s primary and/r secndary sex characteristics because f a marked incngruence with ne s experienced/expressed gender A strng desire fr the primary and/r secndary sex characteristics f the ther gender A strng desire t be f the ther gender A strng desire t be treated as the ther gender This dcument has been classified as public infrmatin.

3 Plicy Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 4/2/19 A strng cnvictin that ne has the typical feelings and reactins f the ther gender Surgery is ANY ONE f the fllwing: Female t male gender reassignment if ANY ONE f the fllwing are met: Mastectmy with nipple/arela recnstructin surgery if ALL f the fllwing are met: One (1) referral letter frm mental health prfessinal with a minimum f a Master s degree r Ph.D. in clinical psychlgy (See ADDITIONAL INFORMATION fr letter criteria) Hysterectmy and variectmy surgery if ALL f the fllwing are met: Dcumentatin f 12 mnths f cntinuus hrmnal therapy (unless the individual has a medical cntraindicatin r is unable r unwilling t take hrmnes). Tw (2) referral letters are needed frm a mental health prfessinal with a minimum f a Master s degree r Ph.D. in clinical psychlgy. If the first referral is frm the patient s psychtherapist, the secnd referral shuld be frm the mental health prfessinal that has nly had an evaluative rle with the patient. (See ADDITIONAL INFORMATION fr letter criteria) Metidiplasty r phallplasty surgery if ALL f the fllwing are met: Dcumentatin f 12 mnths f cntinuus hrmnal therapy (unless the individual has a medical cntraindicatin r is unable r unwilling t take hrmnes). Dcumentatin shws that the individual has lived cntinuusly fr 12 mnths in a real-life experience, in the gender rle that is cngruent with their gender identity Tw (2) referral letters are needed frm a mental health prfessinal with a minimum f a Master s degree r Ph.D. in clinical psychlgy. If the first referral is frm the patient s psychtherapist, the secnd referral shuld be frm the mental health prfessinal that has nly had an evaluative rle with the patient. (See ADDITIONAL INFORMATION fr letter criteria) Male t female gender reassignment if ANY ONE f the fllwing are met: Breast augmentatin with nipple/arela recnstructin surgery if ALL f the fllwing are met: One (1) referral letter frm mental health prfessinal with a minimum f a Master s degree r Ph.D. in clinical psychlgy (See ADDITIONAL INFORMATION fr letter criteria) Dcumentatin f 12 mnths f cntinuus hrmnal therapy (unless the individual has a medical cntraindicatin r is unable r unwilling t take hrmnes). Orchiectmy; penectmy surgery if ALL f the fllwing are met: Dcumentatin f 12 mnths f cntinuus hrmnal therapy (unless the individual has a medical cntraindicatin r is unable r unwilling t take hrmnes). Tw (2) referral letters are needed frm a mental health prfessinal with a minimum f a Master s degree r Ph.D. in clinical psychlgy. If the first referral is frm the patient s psychtherapist, the secnd referral shuld be frm the mental health prfessinal that has nly had an evaluative rle with the patient. (See ADDITIONAL INFORMATION fr letter criteria) Vaginplasty surgery if ALL f the fllwing are met: This dcument has been classified as public infrmatin.

4 Plicy Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 4/2/19 Dcumentatin f 12 mnths f cntinuus hrmnal therapy (unless the individual has a medical cntraindicatin r is unable r unwilling t take hrmnes). Dcumentatin shws that the individual has lived cntinuusly fr 12 mnths in a real-life experience, in the gender rle that is cngruent with their gender identity Tw (2) referral letters are needed frm a mental health prfessinal with a minimum f a Master s degree r Ph.D. in clinical psychlgy. If the first referral is frm the patient s psychtherapist, the secnd referral shuld be frm the mental health prfessinal that has nly had an evaluative rle with the patient. (See ADDITIONAL INFORMATION fr letter criteria) IMPORTANT REMINDERS Any specific prducts referenced in this plicy are just examples and are intended fr illustrative purpses nly. It is nt intended t be a recmmendatin f ne prduct ver anther, and is nt intended t represent a cmplete listing f all prducts available. These examples are cntained in the parenthetical e.g. statement. We develp Medical Plicies t prvide guidance t Members and Prviders. This Medical Plicy relates nly t the services r supplies described in it. The existence f a Medical Plicy is nt an authrizatin, certificatin, explanatin f benefits r a cntract fr the service (r supply) that is referenced in the Medical Plicy. Fr a determinatin f the benefits that a Member is entitled t receive under his r her health plan, the Member's health plan must be reviewed. If there is a cnflict between the Medical Plicy and a health plan, the express terms f the health plan will gvern. ADDITIONAL INFORMATION Accrding t the Standards f Care fr the Health f Transsexual, Transgender, and Gender-Nncnfrming Peple, Versin 7 prvided by the Wrld Prfessinal Assciatin fr Transgender Health (WPATH) letter criteria fr each referral letter shuld address all f the fllwing tpics: Client s general identifying characteristics Results f the client s psychscial assessment, including assessment f gender dysphria and any ther diagnses The duratin f the mental health prfessinal relatinship with the client, including the type f evaluatin and therapy r cunseling t date Other ptins tried t alleviate gender dysphria (e.g. individual therapy, grup and/r family therapy, hrmne therapy) An explanatin that the criteria fr surgery have been met, and a brief descriptin f the clinical ratinale fr supprting the individual s request fr surgery A statement abut the fact that infrmed cnsent has been btained frm the individual A statement that the mental health prfessinal is available fr crdinatin f care and welcmes a phne call t establish this SOURCES American Academy f Child & Adlescent Psychiatry. (2012, September). Practice Parameter n Gay, Lesbian, r Bisexual Sexual Orientatin, Gender Nncnfrmity, and Gender Discrdance in Children and Adlescents. Retrieved June 2, 2017 frm This dcument has been classified as public infrmatin.

5 Plicy Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 4/2/19 American Academy f Pediatrics / American Cllege f Ostepathic Pediatricians. (2016, September) Supprting and caring fr transgender children. Retrieved July 10, 2018 frm American Psychiatric Assciatin. (2011, September). Reprt f the APA Task Frce n Treatment f Gender Identity Disrder. Retrieved September 16, 2013 frm American Psychiatric Assciatin. (2013). Diagnstic and statistical manual f mental disrders (DSM-V ) (5 th ed., pp ). American Psychiatric Publishing. Clebunders, B., Brndeel, S., D Arpa, S., Hebeke, P., & Mnstrey, S. (2016). An update n the surgical treatment fr transgender patients. Sexual Medicine Reviews, 16, Abstract retrieved September 15, 2016 frm PubMed database. Dhejne, C., Lichtenstein, P., Bman, M., Jhanssn, A., La ngstr m, N., and Lande n, M. (2011, February) Lng-term fllw-up f transsexual persns underging sex reassignment surgery: chrt study in Sweden. PLOS One, 6 (2), e (Level 2 evidence) Djrdjevic, M. L., Bizic, M. R., Duisin, D., Buman, M. B., & Buncamper, M. (2016). Reversal surgery in regretful male-t-female transsexuals after sex reassignment surgery. Jurnal f Sexual Medicine, 13 (6), Abstract retrieved September 15, 2016 frm PubMed database. Edwards-Leeper, L., & Spack, N. P. (2012). Psychlgical evaluatin and medical treatment f transgender yuth in an interdisciplinary "Gender Management Service" (GeMS) in a majr pediatric center. Jurnal f Hmsexuality, 59 (3), (Level 5 evidence) Hewitt, J. K., Paul, C., Kasiannan, P., Grver, S. R., Newman, L. K., & Warne, G. L. (2012). Hrmne treatment f gender identity disrder in a chrt f children and adlescents. Jurnal f the Australian Medical Assciatin, 196 (9), (Level 4 evidence) Landén, M., Wålinder, J., Hambert, G., and Lundström, B. (1998, April) Factrs predictive f regret in sex reassignment. Acta Psychiatrica Scandinavica, 94 (4), Abstract retrieved September 13, 2017 frm PubMed database. Murad, M., Elamin, M., Garcia, M., Mullan, R., Murad, A., Erwin, P., and Mntri, V. (2010) Hrmnal therapy and sex reassignment: a systematic review and meta-analysis f quality f life and psychscial utcmes. Database f Abstracts f Reviews f Effects (DARE): Quality-assessed Reviews. Abstract retrieved September 13, 2017 frm PubMed database. Rashid, Mamn and Tamimy, Muhammad (2013, May-August) Phallplasty: the dream and the reality. Indian Jurnal f Plastic Surgery, 46(2), (Level 5 evidence) Spack, N. P., Edwards-Leeper, L. Feldman, H. A., Leibwitz, S., Mandel, F., & Diamnd, D. A. (2012). Children and adlescents with gender identity disrder referred t a pediatric medical center. Pediatrics, 129 (3), (Level 4 evidence) This dcument has been classified as public infrmatin.

6 Plicy Plicy Medical Plicy Manual Apprved Revised Plicy: D Nt Implement Until 4/2/19 Winifred S. Hayes, Inc. Medical Technlgy Directry. (2018, August). Sex reassignment surgery fr the treatment f gender dysphria. Retrieved December 6, 2018 frm (92 articles and r guidelines reviewed) Winifred S. Hayes, Inc. Medical Technlgy Directry. (2014, May; last update search April 2018). Ancillary prcedures and services fr the treatment f gender dysphria. Retrieved December 6, 2018 frm (66 articles and r guidelines reviewed) Winifred S. Hayes, Inc. Medical Technlgy Directry. (2014, May; last update search August 2018). Hrmne therapy fr the treatment f gender dysphria. Retrieved December 6, 2018 frm (127 articles and r guidelines reviewed) Wrld Prfessinal Assciatin fr Transgender Health (WPATH). (2011). Standards f Care fr the health f transsexual, transgender, and gender-nncnfrming peple, versin 7. Retrieved September 13, 2013 frm Zucker, K., Nabbijhn, A., Santarssa, A., Wd, H., Bradley, S., Matthews, J., and VanderLaan, D. (2017) Intense/bsessinal interests in children with gender dysphria: a crss validatin study using the Teacher s Reprt Frm. Child, Adlescent Psychiatry & Mental Health. 11 (15), 1-8. (Level 4 evidence) EFFECTIVE DATE 4/2/2019 ID_BT This dcument has been classified as public infrmatin.

Medical Policy Original Effective Date: 09/24/2014 Revised Date: 09/26/2018 Page 1 of 15 Gender Dysphoria/Gender Identity Disorder Treatment MPM 7.

Medical Policy Original Effective Date: 09/24/2014 Revised Date: 09/26/2018 Page 1 of 15 Gender Dysphoria/Gender Identity Disorder Treatment MPM 7. Page 1 f 15 Disclaimer Refer t the member s specific benefit plan and Schedule f Benefits t determine cverage. This may nt be a benefit n all plans r the plan may have brader r mre limited benefits than