Coverage of any medical intervention discussed in a Prevea360 Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. Reassignment (Sex Transformation) Surgery MP9465

Covered Service: Yes

Services described in this policy are not restricted to those Certificates which contain the Sex Transformation Surgery Rider

Prior Authorization Required: Yes

Additional The medical policy criteria herein govern coverage Information: determinations for Sex Reassignment (Sex Transformation) Surgeries.

Authorization may only be granted if the member is an active participant in a recognized identity treatment program.

Sex Reassignment Surgery is defined as a surgery performed for the treatment of a confirmed diagnosis.

Prevea360 Health Plan Medical Policy: 1.0 All Sex Reassignment Surgeries require prior authorization through the Health Services Division and are considered medically appropriate when all the following are met: 1.1 Letter(s) of referral for surgery from the individual’s qualified professional competent in the assessment and treatment of gender dysphoria, which includes: 1.1.1 Letter of referral should include all the following information: 1.1.1.1 Member’s general identifying characteristics; and 1.1.1.2 Results of the client’s psychological assessment, including any diagnoses; and 1.1.1.3 The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date; and 1.1.1.4 An explanation that the World Professional Association for Health (WPATH) criteria for surgery have been met, and a brief description of the clinical rationale for supporting the member’s request for surgery; and 1.1.1.5 A statement that has been obtained from the member; and 1 of 4 Underwritten by Dean Health Plan, Inc.

Coverage of any medical intervention discussed in a Prevea360 Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. 1.1.1.6 A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this 1.1.2 One letter of referral from a qualified mental health professional (see 1.1) is required for breast/chest surgery (e.g., , chest reconstruction, or augmentation mammoplasty); and 1.1.3 Two independent letters of referral from qualified mental health professionals are required for genital surgery. 1.1.3.1 The first letter must meet the criteria in section 1.1. 1.1.3.2 The second letter is intended to be an evaluative consultation, not a representation of an ongoing long-term therapeutic relationship, and can be written by a qualified mental health provider of sufficient experience with gender dysphoria which has independently assessed the member. This second letter must also meet the criteria of 1.1. 1.1.3.3 Genital reconstructive surgery requires documentation that the member has lived for 12 continuous months in a that is congruent with their . 1.2 Persistent, well-documented gender dysphoria; and 1.3 Capacity to make a fully informed decision and to consent to treatment; and 1.4 Age of majority (18 years of age or older); and 1.5 If significant medical or mental health concerns are present, conditions must be reasonably well-controlled; and 1.6 The member may be required to complete twelve months of continuous and compliant as appropriate to the member’s gender goals (unless the member has a medical contraindication); and 1.6.1 If required documentation of at least 12 months of continuous hormonal sex reassignment therapy; and 1.6.2 The physician responsible for endocrine transition therapy must medically clear the individual for sex reassignment surgery and collaborate with the surgeon regarding hormone use during and after surgery. 1.7 The surgeon performing the procedures is part of an interdisciplinary team that treats patients with gender dysphoria OR has a close association with the mental health and other health professional(s) involved in the treatment of the patient’s gender dysphoria; and has expertise in performing the gender reassignment surgery being requested. Documentation from the surgical provider must include the following: 1.7.1 Surgical history related to previous gender reassignment treatment; AND

Sex Reassignment Surgery 2 of 4 Underwritten by Dean Health Plan, Inc.

Coverage of any medical intervention discussed in a Prevea360 Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. 1.7.2 History of previous hormone treatment; AND 1.7.3 A statement regarding the patient’s gender-related goals for surgery. 1.8 The treatment plan must conform to identifiable external sources including the World Professional Association for Transgender Health Association (WPATH), and/or professional society guidance. 2.0 The following procedures require prior authorization through the Health Services Division and are considered medically appropriate if the criteria in 1.0 are met: 2.1 Male to Female transition: 2.1.1 Breast augmentation mammoplasty and implants 2.1.2 Repair of introitus 2.1.3 Coloproctostomy 2.1.4 2.1.5 Penectomy 2.1.6 2.1.7 Colovaginoplasty 2.1.8 Clitoroplasty 2.1.9 2.2 Female to Male transition: 2.2.1 Breast reduction/mastectomy 2.2.2 Nipple – areola reconstruction (related to mastectomy or post mastectomy reconstruction) 2.2.3 Hysterectomy 2.2.4 Salpingo-oophrectomy 2.2.5 Colpectomy / vaginectomy 2.2.6 2.2.7 2.2.8 Urethroplasty/urethromeatoplasty 2.2.9 Scrotoplasty 2.2.10 Placement of testicular and penile (erectile) prosthesis 2.2.11 Vulvectomy 2.3 Laser of the tissue intended for use in vaginoplasty, labiaplasty, vulvoplasty, clitoroplasty, or penectomy is covered if ALL the criteria in 1.0 to 1.8 are met.

Sex Reassignment Surgery 3 of 4 Underwritten by Dean Health Plan, Inc.

Coverage of any medical intervention discussed in a Prevea360 Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. 3.0 Surgical Procedures accompanying a diagnosis of gender dysphoria that have not been listed above must be reviewed by a Medical Director for medical necessity.

Committee/Source Date(s) Document Medical Policy Committee/Quality and Care Created: Management Division October 31, 2016 Revised: Medical Policy Committee/Quality and Care Management Division December 20, 2017 Medical Policy Committee/Quality and Care Management Division January 17, 2018 Medical Policy Committee/Health Services Division June 19, 2019 Medical Policy Committee/Health Services Division February 19, 2020 Reviewed: Medical Policy Committee/Quality and Care Management Division December 20, 2017 Medical Policy Committee/Quality and Care Management Division January 17, 2018 Medical Policy Committee/Health Services Division June 19, 2019 Medical Policy Committee/Health Services Division February 19, 2020 Medical Policy Committee/Health Services Division June 17, 2020

Published/Effective: 07/01/2020

Sex Reassignment Surgery 4 of 4 Underwritten by Dean Health Plan, Inc.