Gender Dysphoria Treatment in Adults

POLICY NUMBER

L.3.01.401

DESCRIPTION

Children are assigned a gender at birth based upon genital anatomy or chromosomes. Gender dysphoria is defined as discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). Gender nonconformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex. Only some gender-nonconforming people experience gender dysphoria at some point in their lives.

Individualized treatment is available to assist people with such distress to explore their gender identity and find a gender role that is comfortable for them. What helps one person alleviate gender dysphoria might be very different from what helps another person. This process may or may not involve a change in gender expression or body modifications. Medical treatment options include, for example, feminization or masculinization of the body through hormone therapy and/or surgery, which are effective in alleviating gender dysphoria and are medically necessary for many people.

Gender dysphoria can in large part be alleviated through treatment. Hence, while transsexual, transgender, and gender-nonconforming people may experience gender dysphoria at some points in their lives, many individuals who receive treatment will find a gender role and expression that is comfortable for them, even if these differ from those associated with their sex assigned at birth, or from prevailing gender norms and expectations.

Gender Dysphoria Diagnosis Criteria

The criteria for diagnosis of gender dysphoria is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The DSM-5 provides for one overarching diagnosis of gender dysphoria with separate specific criteria for children and for adolescents and adults. The DSM-5 defines gender dysphoria in adolescents and adults as a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:

1. 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)

2. 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)

3. A strong desire for the primary and/or secondary sex characteristics of the other gender

4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)

5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)

6. 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)

In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Gender Dysphoria Treatment Options

Health professionals can assist gender dysphoric individuals with affirming their gender identity, exploring different options for expression of that identity, and making decisions about medical treatment options for alleviating gender dysphoria. For individuals seeking care for gender dysphoria, a variety of therapeutic options can be considered. The number and type of interventions applied and the order in which these take place may differ from person to person. Treatment options include the following:

• Changes in gender expression and role (which may involve living part time or full time in

  another gender role, consistent with one’s gender identity);

• Hormone therapy to feminize or masculinize the body;

• Surgery to change primary and/or secondary sex characteristics (e.g., breasts/chest, external and/or internal genitalia, facial features, body contouring);

• Psychotherapy (individual, couple, family, or group) for purposes such as exploring gender identity, role, and expression; addressing the negative impact of gender dysphoria and stigma on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; or promoting resilience.

Feminizing/Masculinizing Hormone Therapy

Individuals may approach a specialized provider in any discipline to pursue feminizing/ masculinizing hormone therapy. However, transgender health care is an interdisciplinary field, and coordination of care and referral among an individual’s overall care team is recommended.

Hormone therapy can be initiated with a referral from a qualified mental health professional. Alternatively, a health professional who is appropriately trained in behavioral health and competent in the assessment of gender dysphoria may assess eligibility, prepare, and refer the individual for hormone therapy, particularly in the absence of significant coexisting mental health concerns and when working in the context of a multidisciplinary specialty team. The referring health professional should provide documentation—in the chart and/or referral letter—of the individual’s personal and treatment history, progress, and eligibility. Health professionals who recommend hormone therapy share the ethical and legal responsibility for that decision with the physician who provides the service.

Surgical Treatment for Gender Dsyphoria

Gender reassignment surgery is one treatment option for gender dysphoria. Gender reassignment surgery is not a single procedure, but part of a complex process involving multiple medical, psychiatric, and surgical modalities performed in conjunction with each other to help the candidate for gender reassignment achieve successful behavioral and medical outcomes. Before undertaking gender reassignment surgery, candidates need to undergo important medical and psychological evaluations, and begin medical therapies and behavioral trials to confirm that surgery is the most appropriate treatment choice.

Physicians who perform surgical treatments for gender dysphoria should be urologists, gynecologists, plastic surgeons, or general surgeons, and board-certified as such by the relevant national and/or regional association. Surgeons should have specialized competence in genital reconstructive techniques as indicated by documented supervised training with a more experienced surgeon. Even experienced surgeons must be willing to have their surgical skills reviewed by their peers. An official audit of surgical outcomes and publication of these results would be greatly reassuring to both referring health professionals and individuals. Surgeons should regularly attend professional meetings where new techniques are presented. The internet is often effectively used by individuals to share information on their experience with surgeons and their teams.

Ideally, surgeons should be knowledgeable about more than one surgical technique for genital reconstruction so that they, in consultation with individuals, can choose the ideal technique for each individual. Alternatively, if a surgeon is skilled in a single technique and this procedure is either not suitable for or desired by an individual, the surgeon should inform the individual about other procedures and offer referral to another appropriately skilled surgeon.

POLICY

Hormone Therapy

1. Feminizing/Masculinizing Hormone Therapy

   Feminizing/masculinizing hormone therapy is considered medically necessary for adults 18 years of age and older when the Member has a referral from a qualified mental health professional (see Policy Guidelines) for hormone therapy documented in the medical record that includes all of the following:

   1. The individual’s general identifying characteristics, AND

   2. Results of the individual’s psychosocial assessment, including any diagnoses, AND

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

   4. An explanation that the following criteria for hormone therapy have been met:

      1. Persistent, well-documented gender dysphoria as defined in the DSM-5,

      2. Capacity to make a fully informed decision and to consent for treatment,

      3. If significant medical or mental health concerns are present, they must be reasonably well-controlled, AND

   5. A brief description of the clinical rationale for supporting the individual’s request for hormone therapy, AND

   6. A statement that informed consent has been obtained from the individual, AND

   7. A statement that the referring health professional is available for coordination of care.

Hormone therapy that does not meet the criteria above is considered not medically necessary.

Gender Reassignment Surgery

Prior approval is required for Gender Reassignment Surgery.

1. Qualifications for Gender Reassignment Surgery

   Gender reassignment surgery is considered medically necessary when ALL of the following criteria are met:

   1. Member is at least 18 years of age at the time prior approval is requested and the treatment plan is submitted, AND

   2. Member has a diagnosis of gender dysphoria as defined in the DSM-5 by a qualified mental health professional that meets ALL of the following:

      1. New gender identity has been present for at least 24 continuous months, AND

      2. Member has a strong desire to be rid of primary and/or secondary sex, AND characteristics because of a marked incongruence with the member’s identified gender, AND

      3. Member’s gender dysphoria is not a symptom of another mental disorder or chromosomal abnormality, AND

      4. Gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning, AND

   3. Member meets ALL of the following criteria:

      1. For reconstructive chest surgery:

         1. One referral from a qualified mental health professional (see Policy Guidelines)

      2. For reconstructive genital surgery:

         1. Living 12 months of continuous, full time, real life experience in the desired gender (including place of employment, family, social and community activities), AND

         2. 12 months of continuous hormone therapy appropriate to the Member’s gender identity, AND

         3. Two referral letters from qualified mental health professionals (see Policy Guidelines) – one must be from the psychotherapist who has treated the Member for at least 12 continuous months. Letters must document: diagnosis of persistent and chronic gender dysphoria; any existing co-morbid conditions are stable; Member is prepared to undergo surgery and understands all practical aspects of the planned surgery, AND

         4. If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled.

2. Medically Necessary Gender Reassignment Surgical Procedures

   The following gender reassignment surgical procedures for treatment of gender dysphoria may be considered medically necessary when all of the Gender Dysphoria criteria in Section I. above are met:

   1. Initial augmentation mammaplasty with breast implants and nipple-areola reconstruction (creation of breasts)

   2. Clitoroplasty (creation of clitoris)

   3. Hysterectomy (removal of uterus)

   4. Labiaplasty (creation of labia)

   5. Laser or electrolysis hair removal in advance of genital reconstruction

   6. Mastectomy (removal of breasts)

   7. Metoidioplasty (creation of penis, using clitoris)

   8. Orchiectomy (removal of testicles)

   9. Penectomy (removal of penis)

   10. Penile prosthesis

   11. Phalloplasty (creation of penis)

   12. Salpingo-oophorectomy (removal of fallopian tubes and ovaries)

   13. Scrotoplasty (creation of scrotum)

   14. Testicular prostheses

   15. Urethroplasty (reconstruction of female urethra)

   16. Urethroplasty (reconstruction of male urethra)

   17. Vaginectomy (removal of vagina)

   18. Vaginoplasty (creation of vagina) 

3. Non-Covered Cosmetic Procedures and Services

   The following procedures, are considered cosmetic and not eligible for coverage when performed as part of surgical treatment for gender dysphoria:

   1. Abdominoplasty

   2. Blepharoplasty

   3. Body contouring (e.g., fat transfer, lipoplasty, panniculectomy)

   4. Subsequent breast enlargement surgery

   5. Brow lift

   6. Calf implants

   7. Cheek, chin and nose implants

   8. Face/forehead lift and/or neck tightening

   9. Facial bone remodeling for facial feminization

   10. Hair transplantation

   11. Injection of fillers or neurotoxins

   12. Laser or electrolysis hair removal not related to genital reconstruction

   13. Lip augmentation

   14. Lip reduction

   15. Liposuction (suction-assisted lipectomy)

   16. Mastopexy

   17. Pectoral implants for chest masculinization

   18. Rhinoplasty

   19. Skin resurfacing (e.g., dermabrasion, chemical peels, laser)

   20. Thyroid cartilage reduction/reduction thyroid chondroplasty/trachea shave (removal or reduction of the Adam’s apple)

   21. Voice modification surgery (e.g., laryngoplasty, glottoplasty or shortening of the vocal cords)

   22. Voice lessons and voice therapy

   23. Reversal of gender reassignment surgery

All other surgical procedures for treatment of gender dysphoria are considered not medically necessary.

POLICY EXCEPTIONS

Self-funded Groups (unless specified)

State Health Plan (State and School Employees)

Federal Employee Program (FEP)

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the individual's specific benefit plan language.

Qualified Healthcare Professionals for Diagnosis and Treatment of Gender Dysphoria

The training of mental health professionals competent to work with gender dysphoric adults rests upon basic general clinical competence in the assessment, diagnosis, and treatment of mental health concerns. Clinical training may occur within any discipline that prepares mental health professionals for clinical practice, such as psychology, psychiatry, social work, mental health counseling, marriage and family therapy, nursing, or family medicine with specific training in behavioral health and counseling. The following are recommended minimum credentials for mental health professionals who work with adults presenting with gender dysphoria:

1. A master’s degree or its equivalent in a clinical behavioral science field. This degree, or a more advanced one, should be granted by an institution accredited by the appropriate national or regional accrediting board. The mental health professional should have documented credentials from a relevant licensing board.

2. Competence in using the DSM-5 for diagnostic purposes.

3. Ability to recognize and diagnose coexisting mental health concerns and to distinguish these from gender dysphoria.

4. Documented supervised training and competence in psychotherapy or counseling.

5. Knowledgeable about gender-nonconforming identities and expressions, and the assessment and treatment of gender dysphoria.

6. Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

1. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

2. appropriate with regard to standards of good medical practice; and

3. not solely for the convenience of the Member, his or her Provider; and

4. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

05/20/2022: New policy added. Approved by the Medical Policy Advisory Committee.

10/18/2023: Policy reviewed; no changes.

SOURCE(S)

1. Blue Cross and Blue Shield Service Benefit Plan

2. World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People [7th Version].

   https://www.wpath.org/publications/soc

   .

3. https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria

4. Cigna Treatment of Gender Dysphoria Medical Coverage Policy

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Medically Necessary Codes

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