Description
Gender dysphoria (GD) is the formal diagnosis used by professionals to describe persons who experience significant gender dysphoria (discontent with their biological sex and/or birth gender). Although it is a psychiatric classification, GD is not medically classified as a mental illness.

In the U.S., the American Psychiatric Association (APA) permits a diagnosis of gender dysphoria in adolescents and adults if the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (DSM-5™) are met. The criteria are:

1. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six month’s duration, as manifested by at least two of the following:
   1. 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)
   2. 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
   3. A strong desire for the primary and/or secondary sex characteristics of the other gender
   4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
   5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
   6. 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), AND
2. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Gender dysphoria is a medical condition when the elements of the condition noted above are present. Gender affirmation surgery is one treatment option. Gender affirmation surgery is not a single procedure, but part of a complex process involving multiple medical, psychiatric, and surgical modalities performed in conjunction with each other to help the candidate for gender affirmation achieve successful behavioral and medical outcomes. Before undertaking gender affirmation surgery, candidates need to undergo important medical and psychological evaluations, and begin medical/hormonal therapies and behavioral trials to confirm that surgery is the most appropriate treatment choice. Gender affirmation surgery presents significant medical and psychological risks, and the results are irreversible.

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your provider.

Policy
Gender Affirmation Surgery and Hormone Therapy
Services for gender affirmation surgery and hormone therapy may be considered medically necessary when the criteria below are met. 

Please see the following section “Benefits Application” regarding specific benefit and medical management requirements. 

Benefits Application
Gender affirmation surgery and hormone therapy may be specifically excluded under some health benefit plans. Please refer to the Member’s Benefit Booklet for availability of benefits.

When benefits for gender affirmation surgery and hormone therapy are available, coverage may vary according to benefit design. Some benefit designs for gender affirmation surgery may include benefits for pelvic and/or breast reconstruction. Member benefit language specific to gender affirmation should be reviewed before applying the terms of this medical policy. This medical policy relates only to the services or supplies described herein.

Prior review and certification are required by most benefit plans, and when required, must be obtained or services will not be covered. Some benefit plans provide coverage without a requirement for prior approval or medical necessity review. Please refer to the Member’s Benefit Booklet for specific prior approval or medical necessity review requirements.

If prior authorization and medical necessity review are required for hormone therapy, and related surgical procedures for the treatment of gender dysphoria, the medical criteria and guidelines shown below will be utilized to determine the medical necessity for the requested procedure or treatment. 

When gender affirmation surgery and hormone therapy are covered:
Gender affirmation surgery and hormone therapy may be considered medically necessary when all the following candidate criteria are met and supporting provider documentation is provided:

SURGERY
Candidate Criteria for Adults and Adolescents Age 18 Years and Older for Gender Affirmation Surgery

1. The candidate is at least 18 years of age; and
2. Has been diagnosed with gender dysphoria, including meeting all of the following indications:
   1. A strong conviction to live as some alternative gender different from one’s assigned gender. 
      • Typically accompanied by the desire to make the physical body as congruent as possible with the identified sex through surgery and hormone treatment; and
   2. The affirmed gender identity has been present for at least 6 months; and
   3. If significant medical or mental health concerns are present, they must be reasonably well-controlled; and
   4. The gender dysphoria causes clinical or social distress or impairment in social, occupational, or other important areas of functioning.
3. For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is (Note: for those candidates requesting female to male surgery see item 4 below):
   1. Recommended by a mental health professional and
   2. Provided under the supervision of a physician; and the supervising physician indicates that the patient has taken the hormones as directed.
4. For candidates requesting female to male surgery only:
   1. When the initial requested surgery is solely a mastectomy, the treating physician may indicate that no hormonal treatment (as described in criteria 3. above) is required prior to performance of the mastectomy. In this case, the 12 month requirement for hormonal treatment will be waived only when all other criteria contained in this policy and in the member’s health benefit plan are met. 
5. The candidate has completed a minimum of 12 months of successful continuous full time real-life experience in their affirmed gender, with no returning to their gender assigned at birth. This requirement may be demonstrated by living in their affirmed gender while:
   1. Maintaining part- or full-time employment; or
   2. Functioning as a student in an academic setting; or
   3. Functioning in a community-based volunteer activity as applicable. (For those candidates not meeting this criteria, see item 6. below.)
6. If the candidate does not meet the 12 month time frame criteria as noted in item 5. above, then the treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet these criteria. When submitted, the criteria in item 5. will be waived unless the criteria noted in item 5. above are specified as required in the candidate’s health benefit plan. 

Provider Documentation Criteria for Gender Affirmation Surgery:
The treating clinicians must provide the following documentation. The documentation must be provided in letters from the appropriate clinicians and contain the information noted below.

1. The letters must attest to the psychological aspects of the candidate’s gender dysphoria.
   1. One of the letters must be from a licensed behavioral health professional with an appropriate degree (Ph.D., M.D., Ed.D., D.Sc., D.S.W., Psy.D,) or a master's level degree in a clinical behavioral science field(for example, M.S.W., L.C.S.W., Nurse practitioner [NP], Advanced Practice Nurse [A.P.R.N.], Licensed Professional Counselor [L.P.C.], and Marriage and Family Therapist [M.F.T.] and be capable of adequately evaluating co-morbid psychiatric conditions. When patients with gender dysphoria are also diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder) an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated. Reevaluation by a mental health professional qualified to assess and manage psychotic conditions should be conducted prior to surgery, describing the patient’s mental status and readiness for surgery. It is preferable that this mental health professional be familiar with the patient. No surgery should be performed while a patient is actively psychotic.
   2. One of the letters must be from the candidate’s established primary care provider or behavioral health provider. The letter or letters must document the following:
      1. Whether the author of the letter is part of a gender dysphoria treatment team and/or follows current WPATH Standards of Care or Endocrine Society Guidelines for the Endocrine Treatment of Gender-Dysphoric/ Gender-Incongruent Persons for evaluation and treatment of gender dysphoria; and
      2. The initial and evolving gender, sexual, and other psychiatric diagnoses (if applicable); and
      3. The duration of their professional relationship including the type evaluation that the candidate underwent; and
      4. The eligibility criteria that have been met by the candidate according to the above Standards of Care; and
      5. The physician or mental health professional’s rationale for hormone therapy and/or surgery; and
      6. The degree to which the candidate has followed the treatment and experiential requirements to date and the likelihood of future compliance; and
      7. The extent of participation in psychotherapy throughout the 12 month real-life trial, (if such therapy is recommended by a treating medical or behavioral health practitioner); and
      8. That during the 12 month, real-life experience (for candidates not meeting the 12 month candidate criteria as noted in 6 and 7, the letter should still comment on the candidates ability to function and experience in their affirmed gender identity), persons other than the treating therapist were aware of the candidate’s experience in their affirmed gender identity and could attest to the candidate’s ability to function in their affirmed gender identity.
      9. Demonstrable progress on the part of the candidate in consolidating their affirmed gender identity, including improvements in the ability to handle:
         • Work, family, and interpersonal issues
         • Behavioral health issues, should they exist. 
   3. If the letters specified in 1a and 1b above come from the same clinician, then a letter from a second provider or behavioral health provider familiar with the candidate corroborating the information provided by the first clinician is required.
   4. For members requesting surgical treatment, a letter of documentation must be received from the treating surgeon. If one of the previously described letters is from the treating surgeon, then it must contain the documentation noted in the section below. All letters from a treating surgeon must confirm that:
      1. The candidate meets the “candidate criteria” listed in this policy, and
      2. The treating surgeon feels that the candidate is likely to benefit from surgery, and
      3. The surgeon has personally communicated with the treating mental health provider or physician treating the candidate, and 
      4. The surgeon has personally communicated with the candidate and the candidate understands the ramifications of surgery, including:
         • The required length of hospitalizations,
         • Possible complications of the surgery, and
         • The post-surgical rehabilitation requirements of the various surgical approaches and the planned surgery.

Surgical procedures
The following surgical procedures may be considered medically necessary if the above general criteria have been met AND the procedures are being performed only as a part of the overall treatment plan for gender dysphoria:

1. Genital procedures:
a. Male to Female
• Vaginoplasty
• Vulvoplasty
• Repair of introitus
• Penectomy
• Orchiectomy
• Labiaplasty
• Clitoroplasty

b. Female to Male
• Vaginectomy
• Vulvectomy
• Metoidioplasty
• Phalloplasty
• Penile prosthesis
• Urethroplasty/urethromeatoplasty
• Hysterectomy
• Salpingo-oophorectomy
• Scrotoplasty
• Testicular prostheses
• Testicular expanders

2. Chest procedures
a. Male to Female
• Breast reconstruction including augmentation with implants

b. Female to Male
• Mastectomy
• Nipple-areola reconstruction related to mastectomy reconstruction
• Breast reduction 
• Pectoral implants

Please refer to CAM 082 for procedures that may be considered cosmetic in nature.

The following list consists of procedures considered cosmetic in nature and may not be all-inclusive:

• Liposuction: removal of fat
• Rhinoplasty: reshaping of nose
• Rhytidectomy: face lift
• Blepharoplasty: removal of redundant skin of upper and/or lower eyelids and protruding periorbital fat
• Hair removal/ hair transplantation
• Facial feminizing (e.g., facial bone reduction)
• Chin augmentation: reshaping or enhancing the size of the chin
• Collagen injections
• Lip reduction/enhancement: decreasing/enlarging lip size
• Cricothyroid approximation: voice modification that raises the vocal pitch by simulating contractions of the cricothyroid muscle with sutures
• Trachea shave/reduction thyroid chondroplasty: reduction of the thyroid cartilage
• Laryngoplasty: reshaping of laryngeal framework (voice modification surgery)
• Mastopexy: breast lift

Revision surgery to correct complications or functional impairment resulting from initial gender affirming surgery may be considered MEDICALLY NECESSARY. 

HORMONAL THERAPY
Pubertal delay and gender affirming hormone therapy may be considered medically necessary when all the following candidate criteria are met and supporting provider documentation is provided:

Candidate Criteria (based on World Professional Association for Transgender Health (WPATH) Standards of Care):   

1. The patient has been diagnosed with gender dysphoria, including meeting all of the following indications:
   1. A strong conviction to live as some alternative gender different from one’s assigned gender,
      • Typically accompanied by the desire to make the physical body as congruent as possible with the identified sex through surgery and hormone treatment; and
   2. Any co-existing psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment; and
   3. The gender dysphoria causes clinical or social distress or impairment in social, occupational, or other important areas of functioning.
2. The candidate has completed a minimum of 12 months of successful continuous full time real-life experience in their affirmed gender, with no returning to their gender assigned at birth. This requirement may be demonstrated by living in their affirmed gender while:
   1. Maintaining part- or full-time employment; or
   2. Functioning as a student in an academic setting; or
   3. Functioning in a community-based volunteer activity as applicable. (For those candidates not meeting this criteria, see item 3. below.)
3. If the candidate does not meet the 12 month time frame criteria as noted in item 2. above, then the treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet these criteria. When submitted, the criteria in item 2. will be waived unless the criteria noted in item 2. above are specified as required in the candidate’s health benefit plan

Provider Documentation Criteria for Pubertal Delay and Gender Affirming Hormonal Therapy:
The treating clinicians must provide the following documentation. The documentation must be provided in letters from the appropriate clinicians and contain the information noted below.

1. The letters must attest to the psychological aspects of the candidate’s gender dysphoria 
   1. One of the letters must be from a licensed behavioral health professional with an appropriate degree (Ph.D., M.D., Ed.D., D.Sc., D.S.W., Psy.D), or a master's level degree in a clinical behavioral science field (for example, M.S.W., L.C.S.W., Nurse practitioner [NP], Advanced Practice Nurse [A.P.R.N.], Licensed Professional Counselor [L.P.C.] , and Mariage and Family Therapist [M.F.T] and be capable of adequately evaluating co-morbid psychiatric conditions. 
   2. One of the letters must be from the candidate’s established physician or behavioral health provider. The letter or letters must document the following:
      1. Whether the author of the letter is part of a gender dysphoria treatment team and/or follows current WPATH Standards of Care or Endocrine Society Guidelines for the Endocrine Treatment of Gender-Dysphoric/ Gender-Incongruent Persons for evaluation and treatment of gender dysphoria; and
      2. The initial and evolving gender, sexual, and other psychiatric diagnoses (if applicable); and
      3. The duration of their professional relationship including the type evaluation that the candidate underwent; and
      4. The eligibility criteria that have been met by the candidate according to the above Standards of Care; and
      5. The physician or mental health professional’s rationale for hormone therapy; and
      6. The degree to which the candidate has followed the treatment and experiential requirements to date and the likelihood of future compliance; and
      7. The extent of participation in psychotherapy throughout the 12 month real-life trial, (if such therapy is recommended by a treating medical or behavioral health practitioner); and
      8. That during the 12 month, real-life experience (for candidates not meeting the 12 month candidate criteria as noted in 6 and 7, the letter should still comment on the candidates ability to function and experience in their affirmed gender identity), persons other than the treating therapist were aware of the candidate’s experience in their affirmed gender identity and could attest to the candidate’s ability to function in their affirmed gender identity.

Prepubertal children do not require medical or surgical treatment, but do require mental health services as listed above.

Criteria for Adolescents Entering Puberty
Adolescents, having reached puberty (Tanner 2), and who have met eligibility and readiness criteria can be treated with GnRH analogues.

The definition of puberty is having reached Tanner stage 2/5 and/or having LH, estradiol levels or testosterone levels, within the pubertal range. These LH, estradiol and testosterone ranges are well-known and published and are broken down by biological male vs. biological female Tanner stage, and nocturnal and diurnal levels. Adolescents are eligible for GnRH treatment, (for suppression of puberty) by these criteria: (same for adults)

1. Have an established diagnosis for GD based on DSM V or ICD-10 criteria;
2. Have experienced puberty to at least Tanner stage 2, which can be confirmed by pubertal levels of LH, estrogen or testosterone;
3. Have experienced pubertal changes that resulted in an increase of their gender dysphoria;
4. Do not suffer from psychiatric comorbidity (that interferes with the diagnostic work-up or treatment);
5. Have adequate psychological and social support during treatment, to include having parental/guardian consent;
6. Demonstrate knowledge and understanding of the expected outcomes of GnRH analogue treatment, cross-sex hormone treatment, and gender affirmation surgeries, as well as the medical and social risks and benefits of gender affirmation; and have been counseled regarding fertility options.

Criteria for Postpubertal Adolescents under the Age of 18 Years
Post-pubertal adolescents under age 18 must meet the same criteria and documentation requirements for treatment as listed above for adults. If those criteria are met, they are eligible for gender affirmation hormonal treatment and treatment for menstrual suppression when gender affirming hormones are not successful in eliminating menses. 

Gender affirmation surgery is rarely appropriate for patients under the age of 18. Requests for mastectomy for female to male transgender individuals age 17 or younger may be considered only in exceptional circumstances on an individual consideration basis.

When gender affirmation surgery and hormone therapy are not covered:

Gender Affirmation Surgery and hormone therapy are non-covered benefits when the member does not have benefits for the services requested contained in their health benefit plan.

Gender Affirmation Surgery and hormonal therapy are considered NOT MEDICALLY NECESSARY for plans offering gender affirmation services when the candidate criteria and provider documentation criteria are not met.

The following procedures as part of gender affirmation surgery are considered NOT MEDICALLY NECESSARY:

• Abdominoplasty
• Calf implants
• Collagen injections
• Hair transplantation
• Lip filler/lip enhancement
• Neck lift/tightening
• Skin resurfacing (e.g. dermabrasion, chemical peels)
• Laryngoplasty/voice modification surgery is considered investigational.

Reversal of gender affirmation surgery, except for revision surgery as outlined in the when covered section, is investigational/unproven therefore considered NOT MEDICALLY NECESSARY.

Autologous tissue flap breast reconstructions are considered NOT MEDICALLY NECESSARY for gender affirmation surgery. 

Fertility preservation, including but not limited to: sperm banking and embryonic freezing is considered NOT MEDICALLY NECESSARY.

Policy Guidelines
Gender affirmation surgery and hormone therapy candidate criteria and care standards are based, in part, on the World Professional Association for Transgender Health (WPATH) and Endocrine Society Guidelines for Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons. 

Definitions

Crossdressing (transvestism): Wearing clothing and adopting a gender role presentation that, in a given culture, is more typical of the other sex.

Disorders of sex development (DSD): Congenital conditions in which the development of chromosomal, gonadal, or anatomic sex is atypical. Some people strongly object to the “disorder” label and instead view these conditions as a matter of diversity, preferring the terms intersex and intersexuality.

Female-to-Male (FtM): Adjective to describe individuals assigned female at birth who are changing or who have changed their body and/or gender role from birth-assigned 
female to a more masculine body or role.

Gender dysphoria: Distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics).

Gender identity: A person’s intrinsic sense of being male (a boy or a man), female (a girl or woman), or an alternative gender (e.g., boygirl, girlboy, transgender, genderqueer, 
eunuch).

Gender nonconforming: Adjective to describe individuals whose gender identity, role, or expression differs from what is normative for their assigned sex in a given culture and 
historical period.

Gender role or expression: Characteristics in personality, appearance, and behavior that in a given culture and historical period are designated as masculine or feminine (that is, more typical of the male or female social role). While most individuals present socially in clearly male or female gender roles, some people present in an alternative gender role such as genderqueer or specifically transgender. All people tend to incorporate both masculine and feminine characteristics in their gender expression in varying ways and to varying degrees.

Genderqueer: Identity label that may be used by individuals whose gender identity and/or role does not conform to a binary understanding of gender as limited to the 
categories of man or woman, male or female.

Male-to-Female (MtF): Adjective to describe individuals assigned male at birth who are changing or who have changed their body and/or gender role from birth-assigned male to a more feminine body or role.

Puberty: The definition of puberty is having reached Tanner stage 2/5 and/or having luteinizing hormone (LH), estradiol and testosterone levels within the pubertal range. These LH, estradiol and testosterone levels are well-known and published and are broken down by biological male versus biological female Tanner stage, and nocturnal and diurnal levels. 

Sex: Sex is assigned at birth as male or female, usually based on the appearance of the external genitalia. When the external genitalia are ambiguous, other components of sex (internal genitalia, chromosomal and hormonal sex) are considered in order to assign sex. For most people, gender identity and expression are consistent with their sex assigned at birth; for transsexual, transgender, and gender nonconforming individuals, gender identity or expression differ from their sex assigned at birth.

Sex reassignment surgery (gender affirmation surgery): Surgery to change primary and/or secondary sex characteristics to affirm a person’s gender identity. Sex reassignment surgery can be an important part of medically necessary treatment to alleviate gender dysphoria.

Tanner Stages (Tanner Staging): Also known as Sexual Maturity Rating (SMR), in an objective classification system that providers use to document and track the development and sequence of secondary sex characteristics of children during puberty. 

Below are the Tanner Stages described in detail for clinical reference. Tanner Stage 1 corresponds to the pre-pubertal form for all three sites of development with progression 
to Tanner Stage 5, the final adult form. Breast and genital staging, as well as other physical markers of puberty such as height velocity, should be relied on more than pubic 
hair staging to assess pubertal development because of the independent maturation of the adrenal axis.

Pubic Hair Scale (both males and females)

• Stage 1: No hair
• Stage 2: Downy hair
• Stage 3: Scant terminal hair
• Stage 4: Terminal hair that fills the entire triangle overlying the pubic region
• Stage 5: Terminal hair that extends beyond the inguinal crease onto the thigh

Female Breast Development Scale

• Stage 1: No glandular breast tissue palpable
• Stage 2: Breast bud palpable under the areola (1st pubertal sign in females)
• Stage 3: Breast tissue palpable outside areola; no areolar development
• Stage 4: Areola elevated above the contour of the breast, forming a “double scoop” appearance
• Stage 5: Areolar mound recedes into single breast contour with areolar hyperpigmentation, papillae development, and nipple protrusion

Male External Genitalia Scale

• Stage 1: Testicular volume < 4 ml or long axis < 2.5 cm
• Stage 2: 4 ml – 8 ml (or 2.5 to 3.3 cm long), 1st pubertal sign in males
• Stage 3: 9 ml – 12 ml (or 3.4 to 4.0 cm long)
• Stage 4: 15 – 20 ml (or 4.1 to 4.5 cm long)
• Stage 5: > 20 ml (or > 4.5 cm long)

Transgender: Adjective to describe a diverse group of individuals who cross or transcend culturally defined categories of gender. The gender identity of transgender people differs to varying degrees from the sex they were assigned at birth.

Transition: Period of time when individuals change from the gender role associated with their sex assigned at birth to a different gender role. For many people, this involves learning how to live socially in “the other” gender role; for others this means finding a gender role and expression that is most comfortable for them. Transition may or may not include feminization or masculinization of the body through hormones or other medical procedures. The nature and duration of transition is variable and individualized.

Transphobia internalized: Discomfort with one’s own transgender feelings or identity as a result of internalizing society’s normative gender expectations.

Transsexual: Adjective (often applied by the medical profession) to describe individuals who seek to change or who have changed their primary and/or secondary sex 
characteristics through femininizing or masculinizing medical interventions (hormones and/or surgery), typically accompanied by a permanent change in gender role.

References

1. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. Text Revision (DSM-IV-TR). American Psychiatric Association. American Psychiatric Association, Inc. July 2000
2. Harry Benjamin International Gender Dysphoria Association, Inc (2001). Standards of Care for Gender Identity Disorders—Sixth Version. International Journal of Transgenderism 5 (1). Available at: http://www.symposion.com/ijt/soc_2001/index.htm  
3. Day P. Trans-gender Reassignment Surgery. Tech Brief Series. New Zealand Health Technology Assessment. NZHTA Report February 2002, volume 1, Number 1. Available at:
4. http://nzhta.chmeds.ac.nz/publications/trans_gender.pdf 
5. Medical Director review, July 2011
6. The World Professional Association for Transgender Health; Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People; 7th Version; July 2012. Accessed at http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=46-55 on 9/21/2016.
7. Specialty Matched Consultant Advisory Panel 12/2012
8. American Psychiatric Association (APA). Gender dysphoria. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5™). Arlington, VA: American Psychiatric Publishing; 2013: 451-459.
9. American College of Obstetricians and Gynecologists (ACOG). Healthcare for transgender individuals. Committee Opinion. No 512. December 2011. Obstet Gynecol 2011; 118:1454-8.
10. Hembree WC, Cohen-Kettenis P, et al. Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. September 2009, 94(9):3132–3154. Accessed at http://press.endocrine.org/doi/pdf/10.1210/jc.2009-0345 on 9/21/2016.
11. Specialty Matched Consultant Advisory Panel 11/2014
12. Specialty Matched Consultant Advisory Panel 11/2015
13. Specialty Matched Consultant Advisory Panel 9/2016
14. Senior Medical Diector review 9/2016
15. Specialty Matched Consultant Advisory Panel 5/2017
16. Specialty Matched Consultant Advisory Panel 5/2018
17. Specialty Matched Consultant Advisory Panel 6/2019
18. The World Professional Association for Transgender Health; Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People; 7th Version; July 2012. Accessed at https://www.wpath.org/media/cms/Documents/SOC%20v7/Standards%20of%20Care_V7%20Full%20Book_English.pdf on 4/27/2020
19. Specialty Matched Consultant Advisory Panel 5/2020
20. Medical Director review 7/2020
21. Medical Director review 9/2020
22. Hembree WC, Cohen-Kettenis P, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. November 2017, 102(11):3869-3903. Accessed at https://academic.oup.com/jcem/article/102/11/3869/4157558 on 9/25/2020.
23. Medical Director review 3/2021
24. Specialty Matched Consultant Advisory Panel 4/2021
25. Medical Director review 6/2021
26. Medical Director review 9/2021
27. Specialty Matched Consultant Advisory Panel 4/2022

Coding Section

Code	Number	Description
CPT	11950 – 11954	Subcutaneous injection of filling material (e.g., collagen)
	15820	Blepharoplasty, lower eyelid
	15821	BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD
	15822	Blepharoplasty, upper eyelid
	15823	BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID
	15824	RHYTIDECTOMY; FOREHEAD
	15825	Rhytidectomy; neck with platysmal tightening (platsymal flap, P – flap)
	15826	Rhytidectomy; glabellar frown lines
	15828	RHYTIDECTOMY; CHEEK, CHIN, AND NECK
	15829	Under Other Repair (Closure) Procedures on the Integumentary System
	15830 – 15839	Under Other Repair (Closure) Procedures on the Integumentary System
	15775	Punch graft for hair transplant; 1 to 15 punch grafts
	15776	Punch graft for hair transplant; more than 15 punch grafts
	15780 – 15787	Dermabrasion
	15788	Chemical peel
	15876 – 15879	Suction assisted lipectomy
	17380	ELECTROLYSIS EPILATION, EACH 30 MINUTES
	19304	Mastectomy Procedures
	19316	Mastopexy
	19318	BREAST REDUCTION
	19324	Mammaplasty, augmentation; without prosthetic implant
	19325	Mammaplasty, augmentation; with prosthetic implant
	19340	Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
	21120 – 21123	Genioplasty
	21125 – 21127	Augmentation, mandibular body or angle; prosthetic material or with bone graft, onlay or interpositional (includes obtaining autograft)
	21137	Reduction forehead; contouring only
	21138	Reduction forehead: contouring and application of prosthetic material or bone graft (includes obtaining autograft)
	21139	Reduction forehead; contouring and setback of anterior frontal sinus wall
	21208	Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)
	21209	Osteoplasty, facial bones; reduction
	21210	Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
	21270	Malar augmentation, prosthetic material
	21299	Unlisted craniofacial and maxillofacial procedure
	21499	Unlisted musculoskeletal procedure, head
	30400 – 30420	Reconstruction of nose
	30430 – 30450	Revision of nose
	54400 – 54417	Insert semi- rigid prosthesis
	54660	Revision of testis
	55175	Revison of scrotum
	55180	Revision of scrotum
	55970	Intersex surgery; male to female [a series of staged procedures that includes male genitalia removal, penile dissection, urethral transposition, creation of vagina and labia with stent placement]
	55980	female to male [a series of staged procedures that include penis and scrotum formation by graft, and prostheses placement]
	56800	Plastic repair of introitus
	56805	Clitoroplasty for intersex state
	57291 – 57292	Construction of artificial vagina
	57295	Revise vag graft via vagina
	57296	Under Repair Procedures on the Vagina
	57335	Under Repair Procedures on the Vagina
	67900	Under Repair (Brow Ptosis, Blepharoptosis, Lid Retraction, Ectropion,  Entropion) Procedures on the Eyelids
	92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
	92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, two or more individuals
HCPCS	C1813	Prosthesis, penile, inflatable
	C2622	Prosthesis, penile, non-inflatable
	J1950	(Injection, leuprolide acetate [for depot suspension], per 3.75 mg) should only be reported with non-oncologic diagnoses
	J3315	Injection, triptorelin pamoate, 3.75 mg
	J9217	Leuprolide acetate (for depot suspension), 7.5 mg
	J9219	Leuprolide acetate implant, 65 mg
	J9226	Histrelin implant (supprelin la), 50 mg
ICD-10 Diagnosis Code	F64.0	Transsexualism
	F64.1	Dual role transvestism
	F64.2	Gender identity disorder of childhood
	F64.8	Other gender identity disorders
	F64.9	Gender identity disorder, unspecified
	Z87.890	Personal history of sex reassignment

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology^© American Medical Association. All Rights Reserved" 

History From 2022 Forward     

01/03/2024	Annual review, no change to policy intent. Adding list of procedures cosmetic in nature.
02/06/2023	Updated typo in coding section.
11/01/2022	New Policy