Medical Policy

Policy Num:      04.002.004
Policy Name:    GENDER AFFIRMING SURGERY
Policy ID:          [04.002.004]  [Ac / L / M+ / P+]  [0.00.00]

Last Review:       October 24, 2024
Next Review:      October 20, 2025

Related Policies: N/A

GENDER AFFIRMING SURGERY

Summary

This policy addresses gender affirming surgery (also known as sex affirmation surgery, gender or sex reassignment surgery, gender or sex confirmation surgery). Gender affirming surgery is a treatment option for gender dysphoria, a condition in which a person experiences persistent incongruence between gender identity and sexual anatomy at birth. Gender affirming surgery is not an isolated intervention; it is part of a complex process involving multiple medical, psychiatric and psychologic, and surgical specialists working in conjunction with each other and the individual to achieve successful behavioral and medical outcomes. Before undertaking gender affirming surgery, medical and psychological evaluations, medical therapies and behavioral trials are undertaken to help ensure that surgery is an appropriate treatment choice for the individual.

Objective

The objective of this policy is to determine whether gender affirming surgical procedures improves the net health outcome in individuals with gender dysphoria.

Policy Statements 

Gender affirming surgery is considered medically necessary for the treatment of individuals with gender dysphoria when the following criteria is met:

1.     Reached at least 21 years of age, and

2.     Insured must have the ability to make a fully informed decision and give consent for treatment, and

3.     Have been diagnosed with persistent gender dysphoria,

4.     Lived continuously for at least 6 months in the gender role (real-life experiences) that is consistent with the preferred gender, without periods of time to return to the original sex of the person, and 

5.     Completed at least 12 months of continuous hormonal of any male to female (MTF) or female to male (FTM)*  and 

6.     Subjected to a urological examination to identify and treat genitourinary anomalies**, and

7.     One referral from a qualified health professional is needed for surgery. 

*Note: A trial of hormone therapy is not required to qualify for a mastectomy.

**Note: Only recommended for genitourinary surgeries

The following gender affirming services are considered medically necessary for a person who has met the selection criteria mentioned above: 

Male to female

•       Clitoroplasty

•       Coloproctostomy

•       Colovaginoplasty

•       Labiaplasty

•       Orchiectomy

•       Penectomy

•       Perineoplasty

•       Investment of penile skin

•       Repair of the introit

•       Urethroplasty

•       Vaginoplasty with vaginal construction with graft, and/or vulvoplasty

•       Total breast reconstruction

•       Voice modification (surgery or therapy)

•       Elimination of hair on thorax 

•       Flaps, grafts, and/or tissue transfer directly related to a genital reconstructive procedure

Female to male

•       Hysterectomy

•       Metoidioplasty

•       Phalloplasty

•       The placement (and removal if necessary) of an implantable erectile prosthesis

•       The placement of testicular prostheses

•       Salpingo-oophorectomy

•       Subcutaneous mastectomy

•       Vaginectomy, also known as colpectomy

•       Vulvectomy

•       Urethroplasty

•       Urethromeatoplastia

•       Scrotoplasty

•       Testicular expanders

•       Flaps, grafts, and/or tissue transfer directly related to a genital reconstructive procedure

 The following procedures or services are considered cosmetic or not medically necessary when used to improve the gender of a person who intends to undergo, or has undergone gender affirming surgery, including but not limited to: 

•       Abdominoplasty

•       Blepharoplasty

•       Brow lift

•       Cheek implants

•       Nose or chin implants

•       Collagen injections

•       Facelift

•       Facial reconstruction bone / sculpture / reduction, including shortening of the jaw

•       Forehead or conturing

•       Hair transplant

•       Reducing lips or lip augmentation

•       Liposuction or body conturing

•       Rhytidectomy

•       Reduction or shaving trachea, thyroid chondroplasty

•       Elimination of redundant skin

•       Rhinoplasty

•       Skin rejuvenation

•       Voice modulation theraphy

Psychotherapy is not necessary for the gender affirming surgery, except when the initial assessment of mental health professional recommends psychotherapy that specifies treatment goals, estimates of frequency and duration throughout the real life experience.

NOTE: Psychotherapy services may be included in specific components of coverage allowed for some benefit plans. Therefore, CAREFULLY REVIEW the member's benefit plan, summary plan description or contract for GRS provisions. If there is a discrepancy between a medical policy and affiliate benefit plan, the summary plan description or contract, the benefit plan, the summary plan description or contract will govern. 

Policy Guidelines

 The recommended content of the referral letters for surgery is as follows:

1. The client’s general identifying characteristics;

2. Results of the client’s psychosocial assessment, including any diagnoses;

3. The duration of the health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;

4. 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;

5. A statement that informed consent has been obtained from the patient;

6. A statement that the treating professional is available for coordination of care and welcomes a phone call to establish this.

DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents
A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by two or more of the following:

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)
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 condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Benefit Application 

Gender affirmation surgery and hormone therapy may vary across benefit plans. Please refer to the member's benefit plan for coverage details.

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

N/A

Regulatory Status

N/A

Rationale

Population Reference No. 1 Policy Statement

For individuals with gender dysphoria.  Interventions of interest are gender affirming related procedures.  Comparators of interest are hormonal therapy alone or no therapy. Relevant outcomes include improvement of behavioral health and overall quality of life.

Supplemental Information

N/A

References

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Codes

Policy History