Coverage for gender reassignment surgery (GRS) is determined according to individual or group customer benefits. When a covered benefit for gender reassignment surgery (55970, 55980) exists, it may be considered medically necessary when all of the following criteria are met:
- The individual is at least 18 years of age.
- The individual has been diagnosed with the Gender Dysphoria of transsexualism, including all of the following:
- The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
- The individual's transsexual identity has been present persistently for at least two years; and
- The disorder is not a symptom of another mental disorder or a chromosomal abnormality; and
- The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The individual is an active participant in a recognized gender identity treatment program and demonstrates all of the following conditions:
- The individual has successfully lived and worked within the desired gender role full-time for at least 12 months (real life experience) without returning to the original gender
- Initiation of hormonal therapy or breast surgery recommended by a qualified health professional with written documentation submitted to the physician responsible for the medical treatment
- Documentation of at least 12 months of continuous hormonal sex reassignment therapy, unless medically contraindicated (May be simultaneous with real life experience.)
- Recommendation for sex reassignment surgery by two qualified mental health professionals recommend sex reassignment surgery with written documentation submitted to the physician performing the genital surgery (At least one letter should be a comprehensive report. Two separate letters or one letter with two signatures is acceptable. One letter from a Master’s degree mental health professional is acceptable if the second letter is from a psychiatrist or Ph.D. clinical psychologist.)
- Separate evaluation by the physician performing the genital surgery
Surgical Treatment for Gender Reassignment
When a covered benefit for gender reassignment surgery exists and all of the above criteria are met, the following genital surgeries may be medically necessary for transwomen (male to female):
- Orchiectomy (54520, 54690)
- Penectomy (54125)
- Vaginoplasty (57335)
- Colovaginoplasty (57291-57292)
- Clitoroplasty (56805)
- Labiaplasty (58999)
When a covered benefit for gender reassignment surgery exists and all of the above criteria are met, the following breast and genital surgeries may be medically necessary for transmen (female to male):
- Breast reconstruction (eg, mastectomy [19303-19304], reduction mammoplasty )
- Hysterectomy (58150, 58262, 58291, 58552, 58554, 58571, 58573)
- Salpingo-oophorectomy (58661)
- Colpectomy/Vaginectomy (57110)
- Metoidioplasty (55899)
- Phalloplasty (55899)
- Urethroplasty (53430)
- Scrotoplasty (55175, 55180)
- Testicular prostheses implantation (54660)
The following procedures are considered cosmetic services and generally non-covered, when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender reassignment surgery (this list may not be all-inclusive):
- Liposuction (15876-15879)
- Removal of redundant skin (15830, 15832-15839)
- Rhinoplasty (30400, 30410, 30420, 30430, 30435, 30450)
- Breast augmentation (19324-19325)
- Nipple/areola reconstruction (19350)
- Mastopexy (19316)
- Rhytidectomy (15824-15826, 15828-15829)
- Blepharoptosis (67900-67906)
- Blepharoplasty (15820-15823)
- Hair removal – electrolysis (17380) or laser hair removal (17999)
- Hair transplantation (15775- 15776)
- Facial feminizing (eg, facial bone reduction) (21209)
- Chin augmentation (21120-21123, 21125, 21127)
- Lip reduction/enhancement (40799)
- Cricothyroid approximation (21899)
- Trachea shave/reduction thyroid chondroplasty (31899)
- Laryngoplasty (31599)
- Collagen injections (11950-11952, 11954)
See Medical Policy Bulletin S-28 for general information on cosmetic surgery vs. reconstructive surgery.
Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy. Examples include:
- Breast cancer screening may be medically necessary for female to male transgender persons who have not undergone a mastectomy;
- Prostate cancer screening may be medically necessary for male to female transgender individuals who have retained their prostate.
Services that do not meet the criteria of this policy will not be considered medically necessary. A Pennsylvania participating, preferred or network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records. Out of Network/Non-participating providers and providers located outside of Pennsylvania may be able to bill members if the service is denied.
Place of Service: Inpatient/Outpatient
Gender Reassignment Surgery is typically an outpatient procedure which is only eligible or coverage as an inpatient procedure in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
Gender dysphoria, per the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition is a marked incongruence between one’s experienced and or expressed gender and assigned gender, of at least six months duration as manifested by two or more of the following indicators:
- 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
The DSM-5 diagnosis adds a post-transition specifier for people who are living full-time as the desired gender (with or without legal sanction of the gender change). This ensures treatment access for individuals who continue to undergo hormone therapy, related surgery, or psychotherapy or counseling to support their gender transition.
Individuals with gender dysphoria experience confusion in their biological gender during their childhood, adolescence, or adulthood. These individuals demonstrate clinically significant distress or impairment in social, occupational, or other important areas of functioning. Individuals with gender dysphoria may develop social isolation, emotional distress, poor self-image, depression, and anxiety. The diagnosis of gender dysphoria is not made if the individual has a congruent physical intersex condition such as congenital adrenal hyperplasia.
Gender Reassignment Surgery
Gender Dysphoria can be treated with a variety of therapeutic options. The therapeutic approaches to treat this disorder, include psychological interventions, hormone therapy to feminize or masculinize the body, and sexual reassignment therapy (SRT). SRT, either as male-to-female transsexuals (transwomen) or as female-to-male transsexuals (transmen), consists of medical and surgical treatment that changes primary or secondary sex characteristics. Initially, the individual may go through the real-life experience in the desired role, followed by hormonal therapy and surgery to change the genitalia and other sex characteristics.
Transmen assume male gender identities or strive to present in more male gender roles. Gender reassignment surgery from female to male (FTM) includes surgical procedures that reshape a female body into the appearance of a male body. According to the World Professional Association for Transgender Health Standards of Care (WPATH SOC) guidelines, procedures often performed as part of gender reassignment surgery of FTM include mastectomy, hysterectomy, salpingo-oophorectomy, colpectomy (i.e., removal of the vagina, vaginectomy) and metoidioplasty (i.e., clitoral tissue is released and moved forward to approximate the position of a penis, skin from the labia minora is used to create a penis), urethroplasty, scrotoplasty and placement of testicular prosthesis ( i.e., the labia majora is dissected forming cavities allowing for placement of testicular implants) and phalloplasty (i.e., skin tissue graft is used to form a penis). The objectives of phalloplasty may include standing micturation, improved sexual sensation and function and/or appearance.
Transwomen strive for a female identity. Gender reassignment surgery from male to female (MTF) includes procedures that shape a male body into the appearance of and, to the maximum extent possible, the function of a female body. Procedures often performed as part of gender reassignment surgery of MTF according to WPATH SOC include orchiectomy, vaginoplasty, penectomy, and labiaplasty. Surgical techniques vary but may include penile inversion to create a vagina and clitoris or creation of a vagina from the sigmoid colon (i.e., colovaginoplasty). The objectives of vaginoplasty include improved sexual sensation and function and appearance. Breast augmentation may be considered when 18 months of hormone treatment fails to result in breast enlargement that is sufficient for the individual’s comfort in the female gender role.
In order to avoid difficulties with social integration and personal safety issues, it is important to change the individual's legal name and gender on identity documents prior to the surgical process.
Cosmetic services are provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvements alone do not constitute improvement in physiologic function. An individual's sexual satisfaction after the surgery can vary depending on the success of the surgical reassignment technique and on the psychological stability of the individual.
Hormonal interventions and surgical procedures are not without risk for complications; therefore, individuals should undergo an extensive evaluation to explore psychological, family, and social issues prior to and post surgery. Readiness criteria for GRS includes the individual demonstrating progress in consolidating gender identity, and demonstrating progress in dealing with work, family, and interpersonal issues resulting in an improved state of mental health. In order to check the eligibility and readiness criteria for GRS, it is important for the individual to discuss the matter with a professional provider who is well-versed in the relevant medical and psychological aspects of gender dysphoria. The mental health and medical professional providers responsible for the individual's treatment should work together in making a decision about the use of hormones during the months before the GRS. Transsexual individuals should regularly participate in psychotherapy in order to have smooth transitions and adjustments to the new social and physical outcomes.