Medical Policy

Subject: Gender Dysphoria/Gender Identity Disorder Treatment Medical Policy #: 7.3 Original Effective Date: 09/24/2014 Status: Reviewed Last Review Date: 01/22/2020

Disclaimer

Refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in this Medical Policy.

Refer to the Intel Benefit Description for coverage of cosmetic procedures for this treatment.

Description

Gender Dysphoria (GD) is defined by the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, DSM-5 ™ as a condition characterized by the "distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender" also known as “natal gender”, which is the individual’s sex determined at birth. Individuals with gender dysphoria experience confusion in their biological gender during their childhood, adolescence or adulthood. These individuals demonstrate clinically significant distress or impairment in social, occupational, or other important areas of functioning. Gender dysphoria refers to the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration. A diagnosis of gender dysphoria requires a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her. This condition must cause clinically significant distress or impairment in social, occupational or other important areas of functioning. This Medical Policy covers topics related to the treatment of gender dysphoria, including behavioral health evaluation, hormonal therapy and gender reassignment surgery. MPM 18.5 Restorative/Reconstruction/Cosmetic Surgery may be applicable for select surgical procedures.

Coverage Determination

Prior Authorization is required. Gender reassignment surgery will be reviewed on a case-by-case basis by PHP Medical Director. Logon to Pres Online to submit a request: https://ds.phs.org/preslogin/index.jsp

Gender Reassignment (GD)Therapy: GD cannot be treated by psychotherapy or through medical intervention alone. Integrated therapeutic approaches are used to treat GD, including psychological interventions and gender reassignment therapy. gender reassignment therapy, either as male-to-female transsexuals (transwomen) or as female-to-male transsexuals (transmen), consists of medical and surgical treatment that changes primary or secondary sex characteristics. Initially, the individual may go through the real-life experience in the desired role, followed by cross-sex hormone therapy and gender reassignment surgery to change the genitalia and other sex characteristics. The difference between cross- sex hormone therapy and gender reassignment surgery is that the surgery is considered an irreversible physical intervention. Gender reassignment surgical procedures are not without risk for complications; therefore, individuals should undergo an extensive evaluation to explore psychological, family, and social issues prior to and post-surgery. Additionally, certain surgeries may improve gender- appropriate appearance but provide no significant improvement in physiological function. These surgeries are considered cosmetic and are non-covered. Non-Surgical Treatment: Initiation of cross-sex hormone therapy may be provided after a psychosocial assessment has been conducted and informed consent has been obtained by a health professional.

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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The criteria for cross sex hormone therapy are as follows: • Persistent, well-documented gender dysphoria; • Capacity to make a fully informed decision and to consent for treatment; • Member must be at least 18 years of age; • If significant medical or mental health concerns are present, they must be reasonably well controlled.

The presence of co-existing mental health concerns does not necessarily preclude access to cross-sex hormones. These concerns should be managed prior to or concurrent with treatment of gender dysphoria. Cross-sex hormonal interventions are not without risk for complications, including irreversible physical changes. Medical records should indicate that an extensive evaluation was completed to explore psychological, family and social issues prior to and post treatment. Providers should also document that all information has been provided and understood regarding all aspects associated with the use of cross-sex hormone therapy, including both benefits and risks. Readiness for the Treatment of Gender Dysphoria Readiness criteria for gender reassignment surgery includes the individual demonstrating progress in consolidating gender identity, and demonstrating progress in dealing with work, family, and interpersonal issues resulting in an improved state of mental health. In order to check the eligibility and readiness criteria for gender reassignment surgery, it is important for the individual to discuss the matter with a professional provider who is well-versed in the relevant medical and psychological aspects of GD. The mental health and medical professional providers responsible for the individual's treatment should work together in making a decision about the use of cross-sex hormones during the months before the gender reassignment surgery. Transsexual individuals should regularly participate in psychotherapy in order to have smooth transitions and adjustments to the new social and physical outcomes. NOTE: Services or procedures may not be covered when the criteria and documentation requirements outlined within this policy are not met. General Requirements: Surgical treatment of gender reassignment surgery for gender dysphoria may be eligible when medical necessity and documentation requirements outlined within this article are met. Surgical treatment for gender dysphoria may be considered medically necessary when ALL of the following criteria are met: • The individual is at least 18 years of age. • A gender reassignment treatment plan is created specific to an individual beneficiary • The individual has a documented Diagnostic and Statistical Manual of Mental Disorders -Fifth Edition, DSM-5 ™ diagnosis of GD:

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following: • A marked incongruence between one’s experienced/expressed gender and primary and/or 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. • 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).

B. The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning. • One letter from a mental health professional that the patient has had, at minimum, twelve months of psychotherapy therapy sessions attesting to all of the following clinical criteria: o That any co-morbid psychiatric or other medical conditions are stable and that the individual is prepared to undergo surgery. o That the patient has had persistent and chronic gender dysphoria. o That the patient has completed twelve months of continuous, full-time, real-life experience (i.e., the act of fully adopting a new or evolving gender role or gender presentation in everyday life) in the desired gender. • The individual, if required by the mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider.

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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• Unless medically contraindicated (or the individual is otherwise unable to take cross-sex hormones), there is documentation that the individual has participated in twelve consecutive months of cross-sex hormone therapy of the desired gender continuously and responsibly (e.g., screenings and follow-ups with the professional provider). • The individual has knowledge of all practical aspects (e.g., required lengths of hospitalizations, likely complications, and post-surgical rehabilitation) of the gender reassignment surgery.

SURGICAL TREATMENTS FOR GENDER REASSIGNMENT When all of the above criteria are met for gender reassignment surgery, the following genital surgeries may be considered for transwomen (male to female): • Orchiectomy - removal of testicles • Penectomy - removal of penis • Vaginoplasty - creation of vagina • Clitoroplasty - creation of clitoris • Labiaplasty - creation of labia • Prostatectomy -removal of prostate • Urethroplasty - creation of urethra When all of the above criteria are met for gender reassignment surgery, the following genital/breast surgeries may be considered for transmen (female to male): • Breast reconstruction (e.g., mastectomy) - removal of breast • Hysterectomy - removal of uterus • Salpingo-oophorectomy - removal of fallopian tubes and ovaries • Vaginectomy - removal of vagina • Vulvectomy - removal of vulva • Metoidioplasty - creation of micro-penis, using clitoris • Phalloplasty - creation of penis, with or without urethra • Urethroplasty - creation of urethra within the penis • Scrotoplasty - creation of scrotum • Testicular prostheses - implantation of artificial testes Cancer Screenings

Professional organizations such as the American Cancer Society, American College of Obstetricians and Gynecologists and the US Preventive Services Task Force provide recommended cancer screening guidelines to facilitate clinical decision-making by professional providers. Some cancer screening protocols are sex/gender specific based on assumptions about the genitalia for a particular gender.

Trans-Specific cancer screenings (e.g., mammograms, prostate screenings) may be indicated based on the individual's original gender. Gender specific screenings may be medically necessary for transgender persons appropriate to their anatomy. Examples include:

• Breast cancer screening may be medically necessary for transmen who have not undergone a mastectomy. • Prostate cancer screening may be medically necessary for transwomen who have retained their prostate

Exclusions

The following are not covered as part of the treatment for Gender Dysphoria or in conjunction with Gender Reassignment Surgery

Services that are considered cosmetic for the treatment of gender dysphoria are not covered.

This list is not all-inclusive:

• Individuals who have undergone prior gender reassignment surgery. • Sperm or embryo preservation - Cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue. • Abdominoplasty or Panniculectomy • Blepharoplasty: removal of redundant skin of upper and/or lower eyelids and protruding periorbital fat • : reshaping or enhancing the size of the chin • Collagen injections • Construction of a clitoral hood • Corrective facial surgery will be considered cosmetic rather than reconstructive when there is no functional impairment present. However, some congenital, acquired, traumatic or developmental anomalies may not result in

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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functional impairment, but are so severely disfiguring as to merit consideration for corrective surgery. These situations will be handled through the redetermination process. Examples: o Brow lift o Cheek/malar implants o Facial masculinization o Forehead lift o Jaw reduction (jaw contouring) o Osteoplasty • Cricothyroid approximation: voice modification that raises the vocal pitch by simulating contractions of the cricothyroid muscle with sutures • Dermabrasion and chemical peel • Drugs for hair loss or growth • Electrolysis Epilation • Facial feminizing (e.g., facial reduction) • Genioplasty • Hair removal/ hair transplantation • Laryngoplasty: reshaping of laryngeal framework (voice modification surgery) • Lip reduction/enhancement: decreasing/enlarging lip size • Liposuction: removal of fat • Lipectomy • Mammaplasty, augmentation - Cosmetic surgery to improve appearance or self-image is not a benefit. Cosmetic signs or symptoms would include ptosis, poorly fitting clothing and beneficiary perception of unacceptable appearance. Please see Restorative/Reconstructive Cosmetic Surgery and Treatment MPM 18.5 and Breast Surgical Procedures, MPM 27.0 • Mastopexy: breast lift • Neck tightening • Nipple/Areola reconstruction • Pectoral implants • Removal of redundant skin • Rhinoplasty- (reshaping of nose or implants) is not covered when performed for either of the following indications because it is considered cosmetic in nature or not medically necessary: o Solely for the purpose of changing appearance. • Rhytidectomy: face lift • Trachea shave/reduction thyroid chondroplasty to alter the appearance of the thyroid which is without functional defect is considered cosmetic • Voice therapy/Voice lessons

For a list of additional services that are considered cosmetic and therefore, non-covered, please refer to LCD L35090- Cosmetic and Reconstructive Surgery. Cosmetic surgery or expenses incurred in connection with such surgery is not covered. Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member.

Coding

The coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list.

CPT Codes Transwoman procedures (male to female)

54125 Amputation of penis; complete Orchiectomy, simple (including subcapsular), with or without testicular 54520 prosthesis, scrotal or inguinal approach 54690 Laparoscopy, surgical; orchiectomy Laparoscopy, surgical prostatectomy, retropubic radical, including nerve 55866 sparing, includes robotic assistance, when performed **55970 INTERSEX SURGERY; MALE TO FEMALE (see coding instruction below) 56800 Plastic repair of introitus 56805 Clitoroplasty for intersex state 57291 Construction of artificial vagina; without graft 57292 Construction of artificial vagina; with graft 57295 Revision (including removal) of prosthetic vaginal graft; vaginal approach

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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CPT Codes Transwoman procedures (male to female)

Revision (including removal) of prosthetic vaginal graft; open abdominal 57296 approach 57335 Vaginoplasty for intersex state Revision (including removal) of prosthetic vaginal graft, laparoscopic 57426 approach

**When reporting procedure code 55970 (Intersex surgery; male to female), the following staged procedures to remove portions of the male genitalia and form female external genitals are included: • The penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure. • The urethral opening is moved to a position similar to that of a female. • A vagina is made by dissecting and opening the perineum. This opening is lined using pedicle or split- thickness grafts. • Labia are created out of skin from the scrotum and adjacent tissue. • A stent or obturator is usually left in place in the newly created vagina for three weeks or longer.

The following CPT codes will be considered when applicable criteria have been met for Transman procedures (female to male). Note these codes may or may not necessarily be covered.

CPT Codes For Transman procedures (female to male) Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, 19301 segmentectomy) 19303 Mastectomy, simple, complete 19304 Mastectomy, subcutaneous Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous 53420 urethra; first stage Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous 53425 urethra; second stage 53430 Urethroplasty, reconstruction of female urethra 54400 – 54417 Penile prosthesis 54660 Insertion of testicular prosthesis (separate procedure) 55175 Scrotoplasty; simple 55180 Scrotoplasty; complicated **55980 Intersex surgery; female to male. (see coding instruction) 56625 Vulvectomy simple; complete 57106 Vaginectomy, partial removal of vaginal wall; Vaginectomy, partial removal of vaginal wall; with removal of paravaginal 57107 tissue 57110 Vaginectomy, complete removal of vaginal wall; Vaginectomy, complete removal of vaginal wall; with removal of 57111 paravaginal tissue Total abdominal hysterectomy (corpus and cervix), with or without removal 58150 of tube(s), with or without removal of ovary(s); Supracervical abdominal hysterectomy (subtotal hysterectomy), with or 58180 without removal of tube(s), with or without removal of ovary(s) 58260 Vaginal hysterectomy, for uterus 250 g or less; Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), 58262 and/or ovary(s) 58275 Vaginal hysterectomy, with total or partial vaginectomy; Vaginal hysterectomy, with total or partial vaginectomy; with repair of 58280 enterocele 58285 Vaginal hysterectomy, radical 58290 Vaginal hysterectomy, for uterus greater than 250 g; Vaginal hysterectomy, for uterus greater than 250 g; with removal of 58291 tube(s) and/or ovary(s) Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or 58541 less;

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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CPT Codes For Transman procedures (female to male) Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or 58542 less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 58543 250 g; Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 58544 250 g; with removal of tube(s) and/or ovary(s) 58550 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; 58552 with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 58553 250 g; Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 58554 250 g; with removal of tube(s) and/or ovary(s) 58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; 58571 with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 58572 g; Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 58573 g; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical; with removal of adnexal structures (partial or total 58661 oophorectomy and/or salpingectomy) Salpingo-oophorectomy, complete or partial, unilateral or bilateral 58720 (separate procedure)

**When reporting CPT code 55980 (Intersex surgery; female to male), the following staged procedures to form a penis and scrotum using pedicle flap grafts and free skin grafts are included: • Portions of the clitoris are used, as well as the adjacent skin. • Prostheses are often placed in the penis to create a sexually functional organ. • Prosthetic testicles are implanted in the scrotum. • The vagina is closed or removed.

Other covered services. Note these codes may or may not necessarily be covered. CPT Codes Description Subcutaneous hormone pellet implantation (implantation of estradiol 11980 and/or testosterone pellets beneath the skin) Interactive complexity (List separately in addition to the code for primary +90785 procedure) 90832 - 90838 Psychotherapy Therapeutic, prophylactic, or diagnostic injection (specify substance of 96372 drug); subcutaneous or intramuscular

HCPCS codes. Note these codes may or may not necessarily be covered HCPCS Codes Description C1813 Prosthesis, penile, inflatable C2622 Prosthesis, penile, non-inflatable

The following gonadotropin releasing hormone analogs drug HCPCS codes products may or may not necessarily be covered. Refer to Pharmacy. J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg J3315 Injection, triptorelin pamoate, 3.75 mg J3316 Injection, triptorelin, extended release, 3.75 mg J3490 Drugs, unclassified, injection J9202 Goserelin acetate implant, per 3.6 mg J9217 Leuprolide acetate (for depot suspension), 7.5 mg

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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The following gonadotropin releasing hormone analogs drug HCPCS codes products may or may not necessarily be covered. Refer to Pharmacy. J9218 Leuprolide acetate, per 1 mg J9219 Leuprolide acetate implant, 65 mg S0189 Testosterone pellet, 75 mg J1071 Injection, testosterone cypionate, 1 mg J3121 Injection, testosterone enanthate, 1 mg J3145 Injection, testosterone undecanoate, 1 mg J3490 Drugs unclassified injection

HCPCS codes not covered HCPCS Non-covered HCPCS code description Services performed by a qualified speech- language pathologist in the G0153 home health or hospice setting, each 15 minutes S9128 Speech therapy, in the home, per diem

The following CPT codes are considered cosmetic and will not be covered using any ICD-10 Codes listed below. (This list may not be all inclusive)

CPT codes Non-Covered CPT codes description

11950 Subcutaneous injection of filling material (e.g., collagen); 1 cc or less 11951 Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc 11952 Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc 11954 Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc 15775 Punch graft for hair transplant; 1 to 15 punch grafts 15776 Punch graft for hair transplant; more than 15 punch grafts 15820 Blepharoplasty, lower eyelid; 15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad 15822 Blepharoplasty, upper eyelid; 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid 15824 Rhytidectomy; forehead 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, p-flap) 15826 Rhytidectomy; glabellar frown lines 15828 Rhytidectomy; cheek, chin, and neck 15829 Rhytidectomy; superficial musculoaponeurotic system (smas) flap Excision, excessive skin and subcutaneous tissue (includes lipectomy); 15830 abdomen, infraumbilical panniculectomy Excision, excessive skin and subcutaneous tissue (includes lipectomy); 15832 thigh 15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg 15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip Excision, excessive skin and subcutaneous tissue (includes lipectomy); 15835 buttock Excision, excessive skin and subcutaneous tissue (includes lipectomy); 15836 arm Excision, excessive skin and subcutaneous tissue (includes lipectomy); 15837 forearm or hand Excision, excessive skin and subcutaneous tissue (includes lipectomy); 15838 submental fat pad Excision, excessive skin and subcutaneous tissue (includes lipectomy); 15839 other area 15876 Suction assisted lipectomy; head and neck 15877 Suction assisted lipectomy; trunk 15878 Suction assisted lipectomy; upper extremity 15879 Suction assisted lipectomy; lower extremity 17380 Electrolysis epilation, each 30 minutes 19316 Mastopexy 19318 Reduction mammaplasty Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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CPT codes Non-Covered CPT codes description

19324 Mammaplasty, augmentation; without prosthetic implant 19325 Mammaplasty, augmentation; with prosthetic implant Immediate insertion of breast prosthesis following mastopexy, mastectomy 19340 or in reconstruction Delayed insertion of breast prosthesis following mastopexy, mastectomy or 19342 in reconstruction 19350 Nipple/areola reconstruction 21087 Impression and custom preparation; nasal prosthesis 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) 21121 Genioplasty; sliding , single piece Genioplasty; sliding , 2 or more osteotomies (e.g., wedge 21122 excision or bone wedge reversal for asymmetrical chin) Genioplasty; sliding, augmentation with interpositional bone grafts 21123 (includes obtaining autografts) 21125 Augmentation, mandibular body or angle; prosthetic material Augmentation, mandibular body or angle; with bone graft, onlay or 21127 interpositional (includes obtaining autograft) Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; 21193 without bone graft Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; 21194 with bone graft Reconstruction of mandibular rami and/or body, sagittal split; without 21195 internal rigid fixation Reconstruction of mandibular rami and/or body, sagittal split; with internal 21196 rigid fixation Osteoplasty, facial ; augmentation (autograft, allograft, or prosthetic 21208 implant) 21209 Osteoplasty, facial bones; reduction 21210 Graft, bone; nasal, maxillary or malar areas 21270 Malar augmentation, prosthetic material Rhinoplasty, primary; lateral and alar and/or elevation of nasal 30400 tip Rhinoplasty, primary; complete, external parts including bony pyramid, 30410 lateral and alar cartilages, and/or elevation of nasal tip 30420 Rhinoplasty, primary; including major septal repair 30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work) Rhinoplasty, secondary; intermediate revision (bony work with 30435 osteotomies) 30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) 67900 Repair brow ptosis, supraciliary/mid-forehead/coronal approach Treatment of speech, language, voice, communication, and/or auditory 92507 processing disorder; individual Treatment of speech, language, voice, communication, and/or auditory 92508 processing disorder; group, 2 or more individuals

The following ICD-10 Diagnosis codes are considered covered when applicable criteria have been met Only these diagnoses are covered all others diagnosis codes will be Covered ICD-10 Codes denied as non-covered F64.0 Transexualism F64.1 Dual role transvestism F64.8 Other gender identity disorders F64.9 Gender identity disorder, unspecified Z87.890 Personal history of sex reassignment

Reviewed by / Approval Signatures

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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Clinical Quality & Utilization Mgmt. Committee: Howard Epstein MD Senior Medical Director: Norman White MD Date Approved: 01/22/2020 Reviewed by: 1. Bruno Caridi MD, PMG OB/GYN, 201 Cedar St SE, Suite 5600, 87106 2. Gray Clarke MD, Medical Director, PHP Centennial Care, Behavioral Health 3. Julia Gallegos MD, Medical Director, Magellan Health Services, Behavioral Health

References

1. Standards of Care for Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th Version. The World Professional Association for Transgender Health (WPATH). 2012. No changes since 2012. Accessed 12-18- 2019. 2. Multiple Medical Policies Medicare National Coverage Determinations Manual, Chapter 1, Part 2 (Sections 90 – 160.26). Gender reassignment Surgery for Gender Dysphoria, 140.9, A-D, Implemented 04/04/2017. [Cited 12/18/2019] 3. Palmetto GBA, Gender Reassignment Services for Gender Dysphoria (A53793), not in New Mexico region. Revision date: 10/03/2019, R#11. Accessed 12/18/2019 4. Aetna, Gender Reassignment Surgery, Number:0615, Effective: 05/14/2002, Last reviewed: 09/09/2019, Next Review: 06/26/2020, Accessed 09/01/2018. 5. New Mexico, OSI, Bulletin 2018-013, Transgender non-discrimination in Health Insurance Benefits, August 23, 2018. [Cited 05/15/2019] 6. CMS National Coverage Determination (NCD) for Gender Dysphoria and Gender Reassignment Surgery (140.9), Pub# 100-3, Effective Date: 08-30-2016.(No NCD) [Cited 01-02-2020] 7. Hayes, a Division of TractManager, Sex Reassignment Surgery for The Treatment of Gender Dysphoria, Annual Review: Aug 22, 2019. [Cited 01/02/2020] 8. MCG Health Ambulatory Care 23rd Edition, Gonadotropin-Releasing Hormone (GnRH) Agonists (ACG: A-0304 AC), Last Update: 02/11/2019. [Cited 01-02-2020]

Publication History

09-24-2014 Original effective date 12-01-2015 Review 09-26-2018 Annual review. No policy changes. 01/22/2020 Annual review. No policy changes. Updated codes to include HCPCS J1071, J3121, and J3145. Correction on Publication History

This Medical Policy is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. The Medical Policy is not a treatment guide and should not be used as such. For those instances where a member does not meet the criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the medical director in reviewing the case. Please note that all Presbyterian Medical Policies are available online at: Click here for Medical Policies

Web links: At any time during your visit to this policy and find the source material web links has been updated, retired or superseded, PHP is not responsible for the continued viability of websites listed in this policy.

When PHP follows a particular guideline such as LCDs, NCDs, MCG, NCCN etc., for the purposes of determining coverage; it is expected providers maintain or have access to appropriate documentation when requested to support coverage. See the References section to view the source materials used to develop this resource document.

Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001].

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