MPTAC review. The following guidelines were reviewed and may have word changes or clarifications, but had no significant changes to the policy position or criteria. (2 |⊕⊕○○)2.2. This includes coming out to partners, family, friends, and community members (for example, at school, work, and other settings); Regular participation in psychotherapy throughout the real-life experience when recommended by a treating medical or behavioral health practitioner; The individual is at least 18 years of age (see. The duration of 12 months allows for a range of different life experiences and events that may occur throughout the year (e.g., family events, holidays, vacations, season-specific work or school experiences). Benefit language supersedes this document. Quality of life and hormones after sex reassignment surgery. J Psychosom Res. No significant changes to the guideline position or criteria. (Ungraded Good Practice Statement)5.3. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Sex reassignment surgery for female-to-male transgender people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning. 1998; 7(4):284-289. Behavioral Health Subcommittee review. (Ungraded Good Practice Statement)5.4. These operations, which are known clinically as genitoplasty procedures, are done to surgically change the genitalia from one gender to another. Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. 2006; 35(4):501-506. ), involvement in various activities in the desired gender role including work or academic settings, legal acquisition of a gender appropriate first name, and acknowledgement by others of the new gender role. A follow-up study of 13 cases. Procedures such as breast augmentation, liposuction, Adam’s apple reduction, rhinoplasty, facial reconstruction, and others have no medically necessary role in gender identification and are considered cosmetic in nature. New Title: Site of Care: Hospital-Based Ambulatory … 1b. The age threshold should be seen as a minimum criterion and not an indication in and of itself for active intervention. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section; removed CPT 55970, 55980 (not applicable). Note: Not all benefit contracts/certificates include benefits for reconstructive services as defined by this document. We suggest that clinicians begin pubertal hormone suppression after girls and boys first exhibit physical changes of puberty. 2001; 101(5):200-209. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. CG-SURG-27 - Gender Reassignment Surgery; CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities ; CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring . Brentuximab Vedotin (Adcetris®) Revised. Updated formatting in the Clinical Indications section. The general goal of surgery, endocrine therapy, and psychotherapy for individuals diagnosed with GID is lasting personal comfort with the gendered self in order to maximize overall psychological well … However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression. Hormone therapy is consistent with the development of secondary sexual characteristics vital to gender transition, and should be administered unless contraindicated. These procedures, which are known clinically as genitoplasty procedures, are done to surgically change the genitalia from one gender to another. May 2013. CG-GENE-16 - BRCA Testing for Breast and/or Ovarian Cancer Syndrome . This generally involves gender-specific appearance (garments, hairstyle, etc. Among other recommendations this document includes the following: 2.1. Specifically, the term “Gender Identity Disorder (GID)” was replaced with “Gender Dysphoria.”  Additionally, the DSM-5 provided updated diagnostic criteria for gender dysphoria for both children and adults. MPTAC review. The client’s general identifying characteristics; Results of the client’s psychosocial assessment, including any diagnoses; The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date; An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery; A statement about the fact that informed consent has been obtained from the patient; A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this. When told the surgery was not covered by the library’s health insurer, Anthem Blue Cross and Blue Shield, Dovel took the library board/insurance company to court. Arch Sex Behav. RAND Paul likened gender reassignment surgery to "genital mutilation" while grilling a transgender nominee for the Health and Human Services department. Updated Description and References sections. 2005; 35(1):89-99. A strong preference for playmates of the other gender. Dr. Alter specializes in transgender sexual reassignment surgery and has spent decades perfecting his reconstructive techniques. Vaginectomy, complete removal of vaginal wall; Construction of artificial vagina; without graft, Construction of artificial vagina; with graft, Revision (including removal) of prosthetic vaginal graft; vaginal approach, Revision (including removal) of prosthetic vaginal graft; open abdominal approach, Revision (including removal) of prosthetic vaginal graft, laparoscopic approach. 2007; 34(3):557-564. Lindemalm G, Körlin D, Uddenberg N. Prognostic factors vs. outcome in male-to-female transsexualism. Furthermore, they failed to fulfill the complete diagnostic criteria for GID. Gender reassignment surgery (GRS), either as a male-to-female (MTF) transition or as a female-to-male (FTM) transition, consists of medical and surgical treatments that change primary sex characteristics for individuals with gender dysphoria or gender identity disorder who wish to make a permanent transition. J Psychol. 20. The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary when the medical necessity criteria for phalloplasty or vaginoplasty procedures above has been met. Updated Coding section with 01/01/2008 CPT changes. in 1996. MPTAC review. Sex Reassignment Surgery. Here are some examples: Procedures that may be cosmetic, such as removing scars or excess tissue from your eyes or abdomen; Physical therapy, speech therapy … Gender reassignment surgery presents significant medical and psychological risks, and the results are difficult to reverse (Djordjevic, 2016). J Clin Endocrinol Metab. After Lange was told by Anthem Blue Cross and Blue Shield that her insurance would cover gender-confirmation surgery — and had her New York City-based surgeon … PATIENT 1 GENDER CONFIRMATION SURGERY MALE … Added bilateral mastectomy to MN section with criteria. For members below the age of majority (less than 18 years of age), completion of o… Taking the time to understand the unique challenges that transgender employees face when it comes to health care can go a long way toward offering the services and care that benefit all of your employees. An individual can change his hormone levels and undergo surgery to better imitate the opposite sex, but a male on the day of his conception will remain a male on the day of his death. 2013. In summary, there is insufficient high quality data that the use of facial feminization and masculization procedures improve net healthcare outcomes in individuals with gender dysphoria, and no data suggesting that use of these procedures leads to differential healthcare outcomes as compared to non-transgender individuals. Exp Clin Endocrinol Diabetes. Facial corrections in male to female transsexuals: a preliminary report on 16 patients. Single letter of referral from a qualified mental health professional (see Appendix); and 1.2. The goal of vaginoplasty is to create a feminine appearing perineogenital complex with the urethra shortened such that the … J Oral Maxillofac Surg. Anthem Blue Cross California has released information regarding the coverage of medically necessary procedures to treat gender identity disorder, commonly referred to as a person being transgender. The letter(s) must have been signed within 12 months of the request submission. Anthem Blue Cross California has released information regarding the coverage of medically necessary procedures to treat gender identity disorder, commonly referred to as a person being transgender. 8.6.6.1 Male to Female. ], Advanced Practice Nurse [A.P.R.N. Coding updates effective July 1, 2020. Gender reassignment surgery 5 . 1987; 75(3):268-274. Updated Description, Discussion, References and Index sections. With regard to real-life experience, the 2013 WPATH document specifically states: The criterion noted above for some types of genital surgeries – i.e., that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity – is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery. This publication was co-sponsored by the American Association of Clinical Endocrinologists, the American Society of Andrology, the European Society for Pediatric Endocrinology, the European Society of Endocrinology, the Pediatric Endocrine Society, and WPATH. Gender reassignment surgery is considered not medically necessary when one or more of the criteria above have not been met. Anthem Blue Cross PPO Clinical Indications for Gender Reassignment Surgery Gender reassignment surgery is one treatment option for extreme cases of Gender Identity Disorder (GID), a condition in which a person feels a strong and persistent identification with the opposite gender accompanied with a severe sense of discomfort in their own gender. Transgender star, Jessica Alves, can’t wait to have sex following gender reassignment surgery. This document is widely accepted as the definitive document in the area of gender dysphoria treatment, and it has been cited in numerous articles by other respected authors and organizations. Updated criteria regarding confirmation of female gender prior to bilateral mastectomy in female-to-male transitions. J Sex Med. This list has grown from just 49 employers in 2009, to more than 1,000 in 2020. Blanchard R, Steiner BW, Clemmensen LH, Dickey R. Prediction of regrets in postoperative transsexuals. Regarding the necessity and content of referral letters required with requests for genital and chest surgical procedures, the SOC states the following: The recommended content of the referral letters for surgery is as follows: For providers working within a multidisciplinary specialty team, a letter may not be necessary, rather, the assessment and recommendation can be documented in the patient’s chart. Gender Reassignment Surgery Model NCD | 4 urethra, vaginectomy, vulvectomy, scrotoplasty, implantation of erectile and/or testicular prostheses 3. In May 2013, the American Psychiatric Association published an update to its Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5). Individuals with gender dysphoria who undergo gender reassignment procedures may seek additional procedures to further alter their appearance. When services are Not Medically Necessary:For the procedure and diagnosis codes listed above when criteria are not met. Capacity to make a fully informed decision and to consent for treatment; and 1.4. Cohen-Kettenis PT, Gooren LJ. We recommend that, where indicated, GnRH analogues are used to suppress pubertal hormones. *From: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. *CG-SURG-27 Gender Reassignment Surgery. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender. Revised criteria regarding hormone therapy requirements. Surgical Services: An Illustrated Look (Slideshow) Facial Feminization Surgery. 2005; 58(3):259-261. Updated Coding section to include 10/01/2016 ICD-10-CM changes. Surgical augmentation, reduction, or other types of restructuring of the brows, forehead, cheeks, eyes, lips, and/or nose, or some combination of these procedures, may be involved. Transsexualism: a review of etiology, diagnosis and treatment. This diagnosis should not be confused with cross-dressing, refusal to accept homosexual orientation, psychotic delusions, or personality disorders. Djordjevic (2016) reported on the outcomes of surgical reversal surgery in MtF individuals wishing to transition back to male. 2015; 38(12):1373-1381. The WPATH SOC provides the following guidance on this issue: Genital surgery should not be carried out until (i) patients reach the legal age of majority to give consent for medical procedures in a given country, and (ii) patients have lived continuously for at least 12 months in the gender role that is congruent with their gender identity. Hair removal (for example, electrolysis or laser) and hairplasty, when the criteria above have not been met, Thyroid cartilage reduction (chondroplasty). Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner. Changing gender role can have profound personal and social consequences, and the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role. Revised MN criteria for bilateral mastectomy to require one referral letter. 1989; 34(1):43-45. Revised clinical guidelines effective April 15, 2020. Anthem says its “medical policy is applied equitably across all members, regardless of gender or gender identity.” And UnitedHealthcare said in a statement that its “coverage for gender dysphoria treatment is comprehensive and, depending on members’ benefit plans, current coverage may include physician office visits, mental health services, prescription drugs and surgery … Suicide rates among transsexuals and those who have undergone gender reassignment surgery are high with some suggesting the rate may be as high as … A 19-year-old who along with her sister became the world's first twins to undergo a simultaneous gender reassignment operation said the very first shower she had as a … Updated title and document contents to replace “sex reassignment” with “gender reassignment” and “his or her” with “their”. Gender Reassignment Surgery can be super expensive. Hillary Wilson’s illustrations of gender affirming surgery detail facial feminization, three stages of forearm flap phalloplasty and four slides of male to female vaginoplasty. J Psychosom Res. Reviewed clinical guideline effective January 20, 2021. The main goals of surgery are removal of breast tissue and excess skin, reduction and proper positioning of the nipple and areola, and ideally, minimization of chest-wall scars. Updated Rationale and Reference sections. Made minor language revisions to Clinical Indications section. The medical necessity criteria above are based upon the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, Seventh Version, published by the World Professional Association for Transgender Health (WPATH) (2013). Revised. Effective immediately, all new and grandfathered plans will cover surgeries, hormone therapy and counseling associated with transitioning from the birth sex to the sex the individual … If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, 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; Two referrals from qualified mental health professionals* who have independently assessed the individual. People with gender dysphoria often report a feeling of being born the wrong gender. Gender reassignment surgery is not a single procedure, but part of a complex process involving multiple medical, psychiatric, and surgical specialists working in conjunction with each other and the individual to achieve successful behavioral and medical outcomes. MPTAC review. Surgical therapy in transsexual patients: a multi-disciplinary approach. Clin Plast Surg. 6. The Human Rights Campaign has compiled a list of employers that include coverage for at least one transgender-specific service in their employee health plans. Including, but not limited to the following: Gender dysphoria is a condition wherein an individual’s psychological gender identity does not coincide with their anatomic gender. Persistent, well-documented gender dysphoria (see Appendix); and 1.3. Created separate criteria sets for gonad and reproductive organ procedures and for external genital procedures in alignment with the WPATH SOC7. American Psychiatric Association. Updated Discussion, Coding, and References sections. Behavioral Health Subcommittee review. Scand J Plast Reconstr Surg Hand Surg. 2/27/2019. Anthem Blue Cross Clinical Guideline: Surgical Services for Transgender Beneficiaries Page 2 of 17 This document addresses sex reassignment surgery (also known as gender reassignment surgery and Importantly, they cited compliance with accepted preoperative treatment regimes, especially real life experience and psychotherapy, as significant correlates to postoperative success. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance. These operations, which are known clinically as genitoplasty procedures, are done to surgically change the genitalia from one gender to another. Health professionals should clearly document a patient’s experience in the gender role in the medical chart, including the start date of living full time for those who are preparing for genital surgery. 2016; 13(6):988-993. Anthem Blue Cross Blue Shield: Coverage for "Gender Reassignment Surgery" - Al listed surgeries are NOT medically necessary Blue Cross Blue Shield of Massachusetts: Coverage for "Transgender Services" - Al listed surgeries ARE medically necessary*** Blue Cross Blue Shield of North Carolina: Coverage for "Gender Reassignment Surgery" - Al listed surgeries are NOT … Additionally, long-term post-operative follow-up, including availability of mental health services, may also contribute to satisfaction with surgical results. Interestingly, 51 subjects (22%) reported that they did not meet one or more of the minimum eligibility requirements prior to surgery, including less than 12 months of hormone therapy, less than 12 months living in their desired gender role, and less than 12 hours of preoperative psychotherapy. A strong preference for toys, games, or activities stereotypically used or engaged in by the other gender. For male-to-female (MtF) individuals, also known as “transwomen,” surgery involves removal of the testicles and penis and the creation of neovagina, clitoris, and labia. Updated Coding section with 01/01/2020 CPT changes; noted 19304 is deleted effective 12/31/2019.
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