Coverage of any medical intervention discussed in a Dean 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. Sex 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 gender identity treatment program.

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

Medicare Policy: Prior authorization is dependent on the member’s Medicare coverage. Prior authorization is not required for Medicare Cost (Dean Care Gold) and Medicare Supplement (Select) when this service is provided by participating providers. Prior authorization is required if a member has Medicare primary and Dean Health Plan secondary coverage. This policy is not applicable to Dean Health Plan Medicare Replacement products.

BadgerCare Plus Dean Health Plan covers when BadgerCare Plus also covers Policy: the benefit.

Dean 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 of the following are met: 1.1 Letter(s) of referral for surgery from the individual’s qualified mental health professional competent in the assessment and treatment of gender dysphoria, which includes: 1.1.1 Letter of referral should include ALL the following information:

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Coverage of any medical intervention discussed in a Dean 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. 1.1.1.1 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 Transgender 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 informed consent has been obtained from the member; AND 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. mastectomy, 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 gender role that is congruent with their gender identity. 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

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Coverage of any medical intervention discussed in a Dean 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. 1.6 The member may be required to complete twelve months of continuous and compliant hormone therapy 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 member’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 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 Orchiectomy 2.1.5 Penectomy 2.1.6 Vaginoplasty 2.1.7 Colovaginoplasty 2.1.8 Clitoroplasty 2.1.9 Labiaplasty 2.2 Female to Male transition: 2.2.1 Breast reduction/mastectomy Sex Reassignment Surgery 3 of 4

Coverage of any medical intervention discussed in a Dean 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. 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 Metoidioplasty 2.2.7 Phalloplasty 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 hair removal 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. 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 Medical Policy Committee/Health Services Division June 16, 2021 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 Februrary 19, 2020 Medical Policy Committee/Health Services Division June 17, 2020 Medical Policy Committee/Health Services Division June 16, 2021

Published/Effective: 07/01/2021

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