This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

GRS may be considered medically necessary when ALL of the following are met:

• The individual is greater than or equal to 18 years of age; and
• The individual has the capacity to make a fully informed decision and to consent for treatment; and  
• 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 (2) 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; and
  • 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; and
  • Documentation of at least 12 months of continuous hormonal sex reassignment therapy, unless medically contraindicated (may be simultaneous with real life experience); and
  • Recommendation for sex reassignment surgery by two (2) qualified mental health professionals who recommend sex reassignment surgery with written documentation submitted to the physician performing the genital surgery*; and
  • Separate evaluation by the physician performing the genital surgery.

* At least one (1) letter must be a comprehensive report. Two (2) separate letters or one (1) letter with two (2) signatures is acceptable. One (1) letter from a Master’s degree mental health professional is acceptable if the second letter is from a psychiatrist or Ph.D. (clinical psychologist).

When ALL of the above criteria are met, the following breast/genital surgeries may be considered medically necessary for the following indications:

MTF:

• Breast augmentation
• Orchiectomy
• Clitoroplasty  
• Colovaginoplasty
• Labiaplasty
• Orchiectomy
• Penectomy
• Vaginoplasty

Note: Although not a requirement, it is recommended that MTF undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

FTM: 

• Breast reconstruction (e.g., mastectomy)
• Colpectomy/Vaginectomy
• Hysterectomy
• Metoidioplasty
• Penile prosthesis
• Phalloplasty
• Reduction mammoplasty
• Salpingo-oophorectomy
• Scrotoplasty
• Testicular prosthesis implantation
• Urethroplasty

Note: Penile prosthesis surgery is typically performed at stage two (2) or three (3) of a multi-stage phalloplasty (a minimum of nine (9) months following stage one (1)).

The following procedures that may be performed as a component of a gender reassignment are considered cosmetic and, therefore, non-covered (this is not an all-inclusive list):

• Blepharoplasty
• Blepharoptosis 
• Chin augmentation 
• Collagen injections
• Cricothyroid approximation
• Facial bone reduction-facial feminizing
• Hair removal – electrolysisor laser hair removal
• Hair transplantation
• Laryngoplasty
• Lip reduction/enhancement
• Liposuction
• Mastopexy
• Nipple/areola reconstruction
• Removal of redundant skin
• Rhinoplasty
• Rhytidectomy
• Trachea shave/reduction thyroid chondroplasty

Preventive Medicine GRS

Please refer to the member specific benefit plan for screenings (e.g., mammogram, routine gynecological examination, pap smear).

Preventive services are subject to the terms of the member’s individual or group customer benefit

Services that do not meet the criteria of this policy will not be considered medically necessary. A 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.

A network provider can bill the member for the cosmetic service.

A network provider cannot bill the member for the non-covered service.

• Link to Provider Resource Center for the Medical Policy Update

10/2016 Revised criteria for Gender Reassignment Surgery

• Link to Diagnosis Codes

• Link to References