Coding updates effective July 1, 2020. Added note regarding timing of “top” and “bottom” surgical procedures. 2/27/2019. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. Clarification of several Cosmetic indications. (1 |⊕⊕○○)™™2.5. Mate-Kole C, Freschi M, Robin A. 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. Aetna considers gender reassignment surgery medically necessary when all of the following criteria are met: 1. J Oral Maxillofac Surg. Gender Dysphoria / Gender Reassignment Virtually all major insurance companies recognize that transgender-related medical care is medically necessary and have a written policy describing their criteria for when plans they administer will cover it. 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 . 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. 2007; 9(5):318-320. Coverage for "Gender Reassignment Surgery" Anthem Blue Cross Blue Shield: Coverage for "Gender Reassignment Surgery" Blue Cross Blue Shield of Massachusetts: Coverage for "Transgender Services" Blue Cross Blue Shield of North Carolina: Coverage for "Gender Reassignment Surgery" Blue Cross Blue Shield of North Dakota: Coverage for "Medical and Surgical Treatment of Gender … Furthermore, they failed to fulfill the complete diagnostic criteria for GID. As noted in section VII, the social aspects of changing one’s gender role are usually challenging – often more so than the physical aspects. In many instances, the creation of a neovagina or a urethra for a neopenis requires an autologous skin graft from the forearm or thigh. Cristofari S, Bertrand B, Leuzzi S, et al Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study. Br J Psychiatry. Updated Coding, Discussion and Reference sections. All patients featured in this gallery are unique and an individualized treatment plan was developed for each case. 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. ], Advanced Practice Nurse [A.P.R.N. Becking AG, Tuinzing DB, Hage JJ, Gooren LJ. Updated Coding section with 01/01/2021 CPT changes, revised descriptors for codes 19318, 19325; removed deleted ICD-10-PCS codes. 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. Arch Sex Behav. Replaced the word ‘surgeries’ with ‘procedures’ in Cosmetic statement. The Department of Veterans Affairs (VA) has also proposed eliminating its long-standing ban on paying for sex reassignment surgery for America's veterans. J Am Acad Child Adolesc Psychiatry. Updated Coding section with 01/01/2010 CPT changes. Can J Psychiatry. Added CPT codes 54400, 54401, 54405, 55899 (NOC), C1813, C2622, L8699 for penile prosthesis insertion as part of phalloplasty with medical necessity (MN) criteria. Transgender feminization of the facial skeleton. 1997; 131(6):602-614. A strong preference for toys, games, or activities stereotypically used or engaged in by the other gender. 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 … Now 16, she completed Gender Reassignment Surgery in November, according to a posting on her blog. Djordjevic ML, Bizic MR, Duisin D, et al. Hair removal (for example, electrolysis or laser) and hairplasty, when the criteria above have not been met, Thyroid cartilage reduction (chondroplasty). 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. gender reassignment, transcatheter uterine artery embolization • Skilled nursing service in the Home – (fully insured only) • Testicular/penile prosthesis In 2016, Public Library of Cincinnati and Hamilton County library employee Rachel Dovel planned to undergo gender reassignment surgery. Behavioral Health Subcommittee review. Nipple reconstruction, including tattooing, following a mastectomy that meets the medically necessary criteria above is considered medically necessary. Gender confirmation surgery or previously referred to as gender reassignment surgery can transform the life of a transsexual person. Djordjevic (2016) reported on the outcomes of surgical reversal surgery in MtF individuals wishing to transition back to male. 1997; 36(7):872-880. 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. For female-to-male (FtM) individuals, known as “transmen,” surgery involves removal of the uterus, ovaries, and vagina, and creation of a neophallus, and scrotum with scrotal prostheses. In 2003 Lawrence reported the results of a study involving subjects who underwent MtF gender reassignment surgery conducted by a single surgeon. We advise that the clinician responsible for endocrine treatment and the primary care provider ensure appropriate medical clearance of transgender individuals for genital gender-affirming surgery and collaborate with the surgeon regarding hormone use during and after surgery. Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or a congenital defect. One half of Britain's first trans couple to marry after both having gender reassignment surgery has paid tribute to his 'beautiful' and 'inspirational' wife who has died from cancer aged 64. The letter(s) must have been signed within 12 months of the request submission. Updated Coding and Rationale sections. Hepp U, Kraemer B, Schnyder U, et al. NOTE: Reversal of a prior gender reassignment surgery procedure is considered gender reassignment surgery and the medical necessity criteria above apply. PERSONALIZED FOLLOW-UP. 12/18/2019 CG-SURG-27 Gender Reassignment Surgery Previous title: Sex Reassignment Surgery Revised 12/18/2019 CG-SURG-61 Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver Previous title: Cryosurgical Ablation of Solid Tumors Outside the Liver Revised 12/18/2019 CG-SURG-92 Paraesophageal Hernia Repair Revised Surgical Services: An Illustrated Look (Slideshow) Facial Feminization Surgery. … [T]he idea that there is a real personal trait called “gender” that challenges or invalidates the identity significance of biological sex is equally fallacious. 2013. PATIENT 1 GENDER CONFIRMATION SURGERY MALE … Description. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. Added bilateral mastectomy to MN section with criteria. Additionally, real-life experience living as the desired gender is important to validate the individual’s desire and ability to incorporate into their desired gender role within their social network and daily environment. Blanchard R, Steiner BW, Clemmensen LH, Dickey R. Prediction of regrets in postoperative transsexuals. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. Other procedures (rare): voice surgery, liposuction, lipofilling Indications of Coverage Gender Reassignment Surgery is reasonable and necessary when the patient demonstrates: 1. Behavioral Health Subcommittee review. Standards of care for the health of transsexual, transgender, and gender nonconforming people. Added text to MN statement for mastectomy referring reader to see Further Considerations section for individuals under 18 years of age. May 2013. Gender Reassignment Surgery Model NCD | 4 urethra, vaginectomy, vulvectomy, scrotoplasty, implantation of erectile and/or testicular prostheses 3. Added additional procedures to Cosmetic statement. 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. Gender Dysphoria Treatment; Asuris. Breast development in transwomen after 1 year of cross-sex hormone therapy: results of a prospective multicenter study. One study of 188 subjects undergoing gender reassignment surgery found that dissatisfaction with surgery was highly associated with sexual preference, psychological co-morbidity, and poor pre-operative body image and satisfaction (Smith, 2005). In their reversal protocol, each subject was required to have recommendations from three well-known WPATH psychiatrists prior to reversal procedures. are not considered a separate gender reassignment surgery procedure and are not addressed in this document. CG-MED-73. WHOQOL-100 before and after sex reassignment surgery in Brazilian male-to-female transsexual individuals. 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 … Clarified note regarding number of letters required for mastectomy procedures. 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). Capitán L, Simon D, Kaye K, Tenorio T. Facial feminization surgery: the forehead. ], and Marriage and Family Therapist [M.F.T.]) Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Endocr Pract. CG-DME-06 - Pneumatic Compression Devices for Lymphedema 1a. Regardless of the technique used, the procedures are considered equivalent when the intended volume of breast tissue removed is comparable, and the goal of chest surgery is to create a normal male thorax. People with GID … 1999; 46(4):315-333. Similar findings were reported earlier by Schlatterer et al. Added text to referral letter criteria, requiring that letters need to be no more than 12 months old at time of request. 6. A strong desire for the primary and /or secondary sex characteristics of the other gender. Schlatterer K, von Werder K, Stalla GK. 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. Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s). Support from a qualified mental health professional and from peers can be invaluable in ensuring a successful gender role adaptation (Bockting, 2008). Reformatted Coding section and added codes 54400, 54401, 54405, 55899, C1813, C2622, L8699. 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. These studies primarily address the cosmetic results of these surgical procedures, and do not describe the impact of facial feminization procedures on gender dysphoria symptoms or quality of life using a validated or quantifiable methods.. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression. This statement from the SOC does not govern CG-SURG-27. According to the literature on this issue, the predominant factor in requests for reversals are regret, which has been further associated with age greater than 30 at first surgery, personality disorders, early loss of both parents, social instability, preoperative sexual orientation for heterosexual MtF individuals, degree of social support, secondary transsexualism, early decision to undergo surgery and dissatisfaction with surgical results (Blanchard, 1989; Landén, 1998; Lawrence, 2003; Lindemalm, 1986 and 1987; Olsson, 2006). If you or a loved one are considering gender affirmation surgery, you are probably wondering what steps you must go through before the surgery can be done.Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.
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