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.

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1 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 thse listed in these criteria. Refer t the Intel Benefit Descriptin fr cverage f csmetic prcedures fr this treatment. Descriptin Cverage Determinatin and Clinical Indicatins Gender Dysphria (GD) is defined by the Diagnstic and Statistical Manual f Mental Disrders - Fifth Editin, DSM-5 as a cnditin characterized by the "distress that may accmpany the incngruence between ne s experienced r expressed gender and ne s assigned gender" als knwn as natal gender, which is the individual s sex determined at birth. Individuals with gender dysphria experience cnfusin in their bilgical gender during their childhd, adlescence r adulthd. These individuals demnstrate clinically significant distress r impairment in scial, ccupatinal, r ther imprtant areas f functining. Gender dysphria refers t the distress that may accmpany the incngruence between ne s experienced r expressed gender and ne s assigned gender. A marked incngruence between ne s experienced/expressed gender and assigned gender, f at least 6 mnths duratin. A diagnsis f gender dysphria requires a marked difference between the individual s expressed/experienced gender and the gender thers wuld assign him r her. This cnditin must cause clinically significant distress r impairment in scial, ccupatinal r ther imprtant areas f functining. This Medical Plicy cvers tpics related t the treatment f gender dysphria, including behaviral health evaluatin, hrmnal therapy and gender reassignment surgery. MPM 18.5 Restrative/Recnstructin/Csmetic Surgery may be applicable fr select surgical prcedures. Prir Authrizatin is required. Gender reassignment surgery will be reviewed n a case by case basis by PHP Medical Directry. Gender Reassignment (GD)Therapy GD cannt be treated by psychtherapy r thrugh medical interventin alne. Integrated therapeutic appraches are used

2 Page 2 f 15 t treat GD, including psychlgical interventins and gender reassignment therapy. gender reassignment therapy, either as male-t-female transsexuals (transwmen) r as female-t-male transsexuals (transmen), cnsists f medical and surgical treatment that changes primary r secndary sex characteristics. Initially, the individual may g thrugh the real-life experience in the desired rle, fllwed by crss-sex hrmne therapy and gender reassignment surgery t change the genitalia and ther sex characteristics. The difference between crss-sex hrmne therapy and gender reassignment surgery is that the surgery is cnsidered an irreversible physical interventin. Gender reassignment surgical prcedures are nt withut risk fr cmplicatins; therefre, individuals shuld underg an extensive evaluatin t explre psychlgical, family, and scial issues prir t and pst-surgery. Additinally, certain surgeries may imprve gender- apprpriate appearance but prvide n significant imprvement in physilgical functin. These surgeries are cnsidered csmetic and are nn-cvered. Nn-Surgical Treatment Initiatin f crss-sex hrmne therapy may be prvided after a psychscial assessment has been cnducted and infrmed cnsent has been btained by a health prfessinal. The criteria fr crss sex hrmne therapy are as fllws: Persistent, well-dcumented gender dysphria; Capacity t make a fully infrmed decisin and t cnsent fr treatment; Member must be at least 18 years f age; If significant medical r mental health cncerns are present, they must be reasnably well cntrlled. The presence f c-existing mental health cncerns des nt necessarily preclude access t crss-sex hrmnes. These cncerns shuld be managed prir t r cncurrent with treatment f gender dysphria. Crss-sex hrmnal interventins are nt withut risk fr cmplicatins, including irreversible physical changes. Medical recrds shuld indicate that an extensive evaluatin was cmpleted t explre psychlgical, family and scial issues

3 Page 3 f 15 prir t and pst treatment. Prviders shuld als dcument that all infrmatin has been prvided and understd regarding all aspects assciated with the use f crss-sex hrmne therapy, including bth benefits and risks. Readiness fr the Treatment f Gender Dysphria Readiness criteria fr gender reassignment surgery includes the individual demnstrating prgress in cnslidating gender identity, and demnstrating prgress in dealing with wrk, family, and interpersnal issues resulting in an imprved state f mental health. In rder t check the eligibility and readiness criteria fr gender reassignment surgery, it is imprtant fr the individual t discuss the matter with a prfessinal prvider wh is well-versed in the relevant medical and psychlgical aspects f GD. The mental health and medical prfessinal prviders respnsible fr the individual's treatment shuld wrk tgether in making a decisin abut the use f crss-sex hrmnes during the mnths befre the gender reassignment surgery. Transsexual individuals shuld regularly participate in psychtherapy in rder t have smth transitins and adjustments t the new scial and physical utcmes. NOTE: Services r prcedures may nt be cvered when the criteria and dcumentatin requirements utlined within this plicy are nt met. General Requirements: Surgical treatment f gender reassignment surgery fr gender dysphria may be eligible when medical necessity and dcumentatin requirements utlined within this article are met. Surgical treatment fr gender dysphria may be cnsidered medically necessary when ALL f the fllwing criteria are met: The individual is at least 18 years f age. A gender reassignment treatment plan is created specific t an individual beneficiary The individual has a dcumented Diagnstic and Statistical Manual f Mental Disrders -Fifth Editin, DSM-5 diagnsis f GD: A. A marked incngruence between ne s experienced/expressed gender and assigned gender, f at least 6 mnths duratin, as manifested by at least tw f the fllwing:

4 Page 4 f 15 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 (r sme alternative gender different frm ne s assigned gender). A strng desire t be treated as the ther gender (r sme alternative gender different frm ne s assigned gender). A strng cnvictin that ne has the typical feelings and reactins f the ther gender (r sme alternative gender different frm ne s assigned gender). B. The cnditin is assciated with clinically significant distress r impairment in scial, ccupatinal r ther imprtant areas f functining. One letter frm a mental health prfessinal that the patient has had, at minimum, twelve mnths f psychtherapy therapy sessins attesting t all f the fllwing clinical criteria: That any c-mrbid psychiatric r ther medical cnditins are stable and that the individual is prepared t underg surgery. That the patient has had persistent and chrnic gender dysphria. That the patient has cmpleted twelve mnths f cntinuus, full-time, real-life experience (i.e., the act f fully adpting a new r evlving gender rle r gender presentatin in everyday life) in the desired gender. The individual, if required by the mental health prfessinal prvider, has regularly participated in psychtherapy thrughut the real-life experience at a frequency determined jintly by the individual and the mental health prfessinal prvider.

5 Page 5 f 15 Cancer Screenings Unless medically cntraindicated (r the individual is therwise unable t take crss-sex hrmnes), there is dcumentatin that the individual has participated in twelve cnsecutive mnths f crss-sex hrmne therapy f the desired gender cntinuusly and respnsibly (e.g., screenings and fllw-ups with the prfessinal prvider). The individual has knwledge f all practical aspects (e.g., required lengths f hspitalizatins, likely cmplicatins, and pst-surgical rehabilitatin) f the gender reassignment surgery. SURGICAL TREATMENTS FOR GENDER REASSIGNMENT When all f the abve criteria are met fr gender reassignment surgery, the fllwing genital surgeries may be cnsidered fr transwmen (male t female): Orchiectmy - remval f testicles Penectmy - remval f penis Vaginplasty - creatin f vagina Clitrplasty - creatin f clitris Labiaplasty - creatin f labia Prstatectmy -remval f prstate Urethrplasty - creatin f urethra When all f the abve criteria are met fr gender reassignment surgery, the fllwing genital/breast surgeries may be cnsidered fr transmen (female t male): Breast recnstructin (e.g., mastectmy) - remval f breast Hysterectmy - remval f uterus Salping-phrectmy - remval f fallpian tubes and varies Vaginectmy - remval f vagina Vulvectmy - remval f vulva Metidiplasty - creatin f micr-penis, using clitris Phallplasty - creatin f penis, with r withut urethra Urethrplasty - creatin f urethra within the penis Scrtplasty - creatin f scrtum Testicular prstheses - implantatin f artificial testes Prfessinal rganizatins such as the American Cancer Sciety, American Cllege f Obstetricians and Gyneclgists and the US Preventive Services Task Frce prvide recmmended cancer screening guidelines t facilitate clinical

6 Page 6 f 15 decisin-making by prfessinal prviders. Sme cancer screening prtcls are sex/gender specific based n assumptins abut the genitalia fr a particular gender. Trans-Specific cancer screenings (e.g., mammgrams, prstate screenings) may be indicated based n the individual's riginal gender. Gender specific screenings may be medically necessary fr transgender persns apprpriate t their anatmy. Examples include: Breast cancer screening may be medically necessary fr transmen wh have nt undergne a mastectmy. Prstate cancer screening may be medically necessary fr transwmen wh have retained their prstate.. Exclusins The fllwing are nt cvered as part f the treatment fr Gender Dysphria r in cnjunctin with Gender Reassignment Surgery Services that are cnsidered csmetic fr the treatment f gender dysphria are nt cvered. This list is nt all-inclusive: Individuals wh have undergne prir gender reassignment surgery. Sperm r embry preservatin - Crypreservatin/freezing, strage/banking, and thawing f reprductive tissues, such as cytes, varies, embrys, spermatza, and testicular tissue. Abdminplasty r Paniculectmy Blepharplasty: remval f redundant skin f upper and/r lwer eyelids and prtruding perirbital fat Chin augmentatin: reshaping r enhancing the size f the chin Cllagen injectins Cnstructin f a clitral hd Crrective facial surgery will be cnsidered csmetic rather than recnstructive when there is n functinal impairment present. Hwever, sme cngenital, acquired, traumatic r develpmental anmalies may nt result in functinal impairment, but are s severely disfiguring as t merit cnsideratin fr crrective surgery. These situatins will be handled thrugh the redeterminatin prcess. Examples:

7 Page 7 f 15 Brw lift Cheek/malar implants Facial masculinizatin Frehead lift Jaw reductin (jaw cnturing) Osteplasty Cricthyrid apprximatin: vice mdificatin that raises the vcal pitch by simulating cntractins f the cricthyrid muscle with sutures Drugs fr hair lss r grwth Electrlysis Epilatin Facial feminizing (e.g., facial bne reductin) Geniplasty Hair remval/ hair transplantatin Laryngplasty: reshaping f laryngeal framewrk (vice mdificatin surgery) Lip reductin/enhancement: decreasing/enlarging lip size Lipsuctin: remval f fat Lipectmy Mammaplasty, augmentatin - Csmetic surgery t imprve appearance r self-image is nt a Medicare benefit. Csmetic signs r symptms wuld include ptsis, prly fitting clthing and beneficiary perceptin f unacceptable appearance. Please see Restrative/Recnstructive Csmetic Surgery and Treatment MPM Mastpexy: breast lift Neck tightening Nipple/Arela recnstructin Pectral implants Remval f redundant skin Rhinplasty- (reshaping f nse r implants) is nt cvered when perfrmed fr either f the fllwing indicatins because it is cnsidered csmetic in nature r nt medically necessary: Slely fr the purpse f changing appearance. Rhytidectmy: face lift

8 Page 8 f 15 Trachea shave/reductin thyrid chrndplasty t alter the appearance f the thyrid cartilage which is withut functinal defect is cnsidered csmetic Vice therapy/vice lessns Fr a list f additinal services that are cnsidered csmetic and therefre, nn-cvered, please refer t LCD L35090-Csmetic and Recnstructive Surgery. Csmetic surgery r expenses incurred in cnnectin with such surgery is nt cvered. Csmetic surgery includes any surgical prcedure directed at imprving appearance, except when required fr the prmpt (i.e., as sn as medically feasible) repair f accidental injury r fr the imprvement f the functining f a malfrmed bdy member. Cding The cding listed in this medical plicy is fr reference nly. Cvered and nn-cvered cdes are within this list. The fllwing CPT cdes will be cnsidered when applicable criteria have been met fr Transwman prcedures (male t female). CPT Transwman prcedures (male t female) Amputatin f penis; cmplete Orchiectmy, simple (including subcapsular), with r withut testicular prsthesis, scrtal r inguinal apprach Laparscpy, surgical; rchiectmy Laparscpy, surgical prstatectmy, retrpubic radical, including nerve sparing, includes rbtic assistance, when perfrmed INTERSEX SURGERY; MALE TO FEMALE (see cding **55970 instructin belw) Plastic repair f intritus Clitrplasty fr intersex state Cnstructin f artificial vagina; withut graft Cnstructin f artificial vagina; with graft Revisin (including remval) f prsthetic vaginal graft; vaginal apprach Revisin (including remval) f prsthetic vaginal graft; pen abdminal apprach Vaginplasty fr intersex state Revisin (including remval) f prsthetic vaginal graft, laparscpic apprach

9 Page 9 f 15 **When reprting prcedure cde (Intersex surgery; male t female), the fllwing staged prcedures t remve prtins f the male genitalia and frm female external genitals are included: The penis is dissected, and prtins are remved with care t preserve vital nerves and vessels in rder t fashin a clitris-like structure. The urethral pening is mved t a psitin similar t that f a female. A vagina is made by dissecting and pening the perineum. This pening is lined using pedicle r split- thickness grafts. Labia are created ut f skin frm the scrtum and adjacent tissue. A stent r bturatr is usually left in place in the newly created vagina fr three weeks r lnger. The fllwing CPT cdes will be cnsidered when applicable criteria have been met fr Transman prcedures (female t male): CPT Fr Transman prcedures (female t male) Mastectmy, partial (eg, lumpectmy, tylectmy, quadrantectmy, segmentectmy) Mastectmy, simple, cmplete Mastectmy, subcutaneus Urethrplasty, 2-stage recnstructin r repair f prstatic r membranus urethra; first stage Urethrplasty, 2-stage recnstructin r repair f prstatic r membranus urethra; secnd stage Urethrplasty, recnstructin f female urethra Penile prsthesis Insertin f testicular prsthesis (separate prcedure) Scrtplasty; simple Scrtplasty; cmplicated **55980 Intersex surgery; female t male. (see cding instructin) Vulvectmy simple; cmplete Vaginectmy, partial remval f vaginal wall; Vaginectmy, partial remval f vaginal wall; with remval f paravaginal tissue Vaginectmy, cmplete remval f vaginal wall; Vaginectmy, cmplete remval f vaginal wall; with remval f paravaginal tissue Ttal abdminal hysterectmy (crpus and cervix), with r withut remval f tube(s), with r withut remval f vary(s); Supracervical abdminal hysterectmy (subttal hysterectmy), with r withut remval f tube(s), with r withut remval f vary(s) Vaginal hysterectmy, fr uterus 250 g r less;

10 Page 10 f 15 CPT Fr Transman prcedures (female t male) Vaginal hysterectmy, fr uterus 250 g r less; with remval f tube(s), and/r vary(s) Vaginal hysterectmy, with ttal r partial vaginectmy; Vaginal hysterectmy, with ttal r partial vaginectmy; with repair f entercele Vaginal hysterectmy, radical Vaginal hysterectmy, fr uterus greater than 250 g; Vaginal hysterectmy, fr uterus greater than 250 g; with remval f tube(s) and/r vary(s) Laparscpy, surgical, supracervical hysterectmy, fr uterus 250 g r less; Laparscpy, surgical, supracervical hysterectmy, fr uterus 250 g r less; with remval f tube(s) and/r vary(s) Laparscpy, surgical, supracervical hysterectmy, fr uterus greater than 250 g; Laparscpy, surgical, supracervical hysterectmy, fr uterus greater than 250 g; with remval f tube(s) and/r vary(s) Laparscpy, surgical, with vaginal hysterectmy, fr uterus 250 g r less; Laparscpy, surgical, with vaginal hysterectmy, fr uterus 250 g r less; with remval f tube(s) and/r vary(s) Laparscpy, surgical, with vaginal hysterectmy, fr uterus greater than 250 g; Laparscpy, surgical, with vaginal hysterectmy, fr uterus greater than 250 g; with remval f tube(s) and/r vary(s) Laparscpy, surgical, with ttal hysterectmy, fr uterus 250 g r less; Laparscpy, surgical, with ttal hysterectmy, fr uterus 250 g r less; with remval f tube(s) and/r vary(s) Laparscpy, surgical, with ttal hysterectmy, fr uterus greater than 250 g; Laparscpy, surgical, with ttal hysterectmy, fr uterus greater than 250 g; with remval f tube(s) and/r vary(s) Laparscpy, surgical; with remval f adnexal structures (partial r ttal phrectmy and/r salpingectmy) Salping-phrectmy, cmplete r partial, unilateral r bilateral (separate prcedure) **When reprting CPT cde (Intersex surgery; female t male), the fllwing staged prcedures t frm a penis and scrtum using pedicle flap grafts and free skin grafts are included: Prtins f the clitris are used, as well as the adjacent skin. Prstheses are ften placed in the penis t create a sexually functinal rgan. Prsthetic testicles are implanted in the scrtum.

11 Page 11 f 15 The vagina is clsed r remved. Other cvered services CPT Other cvered services Subcutaneus hrmne pellet implantatin (implantatin f estradil and/r teststerne pellets beneath the skin) Interactive cmplexity (List separately in additin t the cde fr primary prcedure) Psychtherapy Therapeutic, prphylactic, r diagnstic injectin (specify substance f drug); subcutaneus r intramuscular Cvered HCPCS cdes HCPCS Cdes C1813 C2622 J1950 J9202 J9217 J9218 J9219 S0189 Cdes cvered if selectin criteria are met: Prsthesis, penile, inflatable Prsthesis, penile, nn-inflatable Injectin, leuprlide acetate (fr dept suspensin), per 3.75 mg Gserelin acetate implant, per 3.6 mg Leuprlide acetate (fr dept suspensin), 7.5 mg Leuprlide acetate, per 1 mg Leuprlide acetate implant, 65 mg Teststerne pellet, 75 mg HCPCS cdes nt cvered HCPCS G0153 S9128 NON cvered HCPCS cde descriptin Services perfrmed by a qualified speech- language pathlgist in the hme health r hspice setting, each 15 minutes Speech therapy, in the hme, per diem The fllwing CPT cdes are cnsidered csmetic and will nt be cvered using any ICD-10 Cdes listed belw. (This list may nt be all inclusive). CPT cdes NON- Cvered CPT cdes descriptin Subcutaneus injectin f filling material (eg, cllagen); 1 cc r less Subcutaneus injectin f filling material (eg, cllagen); 1.1 t 5.0 cc Subcutaneus injectin f filling material (eg, cllagen); 5.1 t 10.0 cc Subcutaneus injectin f filling material (eg, cllagen); ver 10.0 cc Punch graft fr hair transplant; 1 t 15 punch grafts

12 Page 12 f 15 CPT cdes NON- Cvered CPT cdes descriptin Punch graft fr hair transplant; mre than 15 punch grafts Blepharplasty, lwer eyelid; Blepharplasty, lwer eyelid; with extensive herniated fat pad Blepharplasty, upper eyelid; Blepharplasty, upper eyelid; with excessive skin weighting dwn lid Rhytidectmy; frehead Rhytidectmy; neck with platysmal tightening (platysmal flap, p- flap) Rhytidectmy; glabellar frwn lines Rhytidectmy; cheek, chin, and neck Rhytidectmy; superficial musculapneurtic system (smas) flap lipectmy); abdmen, infraumbilical panniculectmy lipectmy); thigh lipectmy); leg lipectmy); hip lipectmy); buttck lipectmy); arm lipectmy); frearm r hand lipectmy); submental fat pad lipectmy); ther area Suctin assisted lipectmy; head and neck Suctin assisted lipectmy; trunk Suctin assisted lipectmy; upper extremity Suctin assisted lipectmy; lwer extremity Electrlysis epilatin, each 30 minutes Mastpexy Reductin mamaplasty Mammaplasty, augmentatin; withut prsthetic implant Mammaplasty, augmentatin; with prsthetic implant Immediate insertin f breast prsthesis fllwing mastpexy, mastectmy r in recnstructin Delayed insertin f breast prsthesis fllwing mastpexy,

13 Page 13 f 15 CPT cdes NON- Cvered CPT cdes descriptin mastectmy r in recnstructin Nipple/arela recnstructin Impressin and custm preparatin; nasal prsthesis Geniplasty; augmentatin (autgraft, allgraft, prsthetic material) Geniplasty; sliding stetmy, single piece Geniplasty; sliding stetmies, 2 r mre stetmies (eg, wedge excisin r bne wedge reversal fr asymmetrical chin) Geniplasty; sliding, augmentatin with interpsitinal bne grafts (includes btaining autgrafts) Augmentatin, mandibular bdy r angle; prsthetic material Augmentatin, mandibular bdy r angle; with bne graft, nlay r interpsitinal (includes btaining autgraft) Recnstructin f mandibular rami, hrizntal, vertical, C, r L stetmy; withut bne graft Recnstructin f mandibular rami, hrizntal, vertical, C, r L stetmy; with bne graft Recnstructin f mandibular rami and/r bdy, sagittal split; withut internal rigid fixatin Recnstructin f mandibular rami and/r bdy, sagittal split; with internal rigid fixatin Osteplasty, facial bnes; augmentatin (autgraft, allgraft, r prsthetic implant) Osteplasty, facial bnes; reductin Graft, bne; nasal, maxillary r malar areas Malar augmentatin, prsthetic material Rhinplasty, primary; lateral and alar cartilages and/r elevatin f nasal tip Rhinplasty, primary; cmplete, external parts including bny pyramid, lateral and alar cartilages, and/r elevatin f nasal tip Rhinplasty, primary; including majr septal repair Rhinplasty, secndary; minr revisin (small amunt f nasal tip wrk) Rhinplasty, secndary; intermediate revisin (bny wrk with stetmies) Rhinplasty, secndary; majr revisin (nasal tip wrk and stetmies) Repair brw ptsis, supraciliary/mid-frehead/crnal apprach Treatment f speech, language, vice, cmmunicatin, and/r auditry prcessing disrder; individual Treatment f speech, language, vice, cmmunicatin, and/r auditry prcessing disrder; grup, 2 r mre individuals

14 Page 14 f 15 The fllwing ICD-10 Diagnsis cdes are cnsidered cvered when applicable criteria have been met: Cvered ICD-10 Cdes Only these diagnsis are cvered all thers diagnsis cdes will be denied as nn-cvered F64.0 Transexualism F64.1 Dual rle transvestism F64.8 Other gender identity disrders F64.9 Gender identity disrder, unspecified Z Persnal histry f sex reassignment Reviewed by 1. Brun Caridi MD, PMG OB/GYN, 201 Cedar St SE, Suite 5600, Gray Clarke MD, Medical Directr, PHP Centennial Care, Behaviral Health 3. Julia Gallegs MD, Medical Directr, Magellan Health Services, Behaviral Health References 4. Standards f Care fr Health f Transsexual, Transgender, and Gender-Nncnfrming Peple, 7 th Versin. The Wrld Prfessinal Assciatin fr Transgender Health (WPATH) N changes since Accessed Multiple Medical Plicies Medicare Natinal Cverage Determinatins Manual, Chapter 1, Part 2 (Sectins ). Gender reassignment Surgery fr Gender Dysphria, 140.9, A-D 6. Palmett GBA, Gender Reassignment Services fr Gender Dysphria (A53793). Accessed 09/01/ Aetna, Gender Reassignment Surgery, Number:0615, Effective: 05/14/2002, Next Review: 06/27/2019, Accessed 09/01/2018. Apprval Signatures Clinical Quality Cmmittee: Thmas Rthfeld MD Medical Directry: Nrman White MD Apprval Dates September 26, 2018 Publicatins Histry 1. Hayes Technlgy Brief, Relieva Balln Sinuplasty (Acclarent Inc.) fr Chrnic Sinusitis in Adults, Published Octber 4, 2012 with review August 28, 2014.

15 Page 15 f 15 Accessed Archived Hayes Technlgy Brief, Relieva Balln Sinuplasty (Acclarent Inc.) fr Chrnic Sinusitis in Children, Published Octber 8, 2012 with review August 28, Accessed Archived MCG, Ambulatry Care Guidelines, 18th Editin. A Last Update 2/5/2014. Accessed 1/7/2015. Accessed th Additin last updated Accessed 1/17/18. 21st Editin last update 2/2/17. N change. 4. American Academy f Otlarynglgy-Head and Neck Surgery (AAO-HNS). Dilatin f sinuses, any methd (e.g., balln, etc.) Plicy Statement. Revised December 6, Available at: Accessed Reaffirmed This Medical Plicy is intended t represent clinical guidelines describing medical apprpriateness and is develped t assist Presbyterian Health Plan and Presbyterian Insurance Cmpany, Inc. (Presbyterian) Health Services staff and Presbyterian medical directrs in determinatin f cverage. The Medical Plicy is nt a treatment guide and shuld nt be used as such. Fr thse instances where a member des nt meet the criteria described in these guidelines, additinal infrmatin supprting medical necessity is welcme and may be utilized by the medical directr in reviewing the case. Please nte that all Presbyterian Medical Plicies are available nline at: Click here fr Medical Plices