Department: Medical Management Original Approval: 07/19/2018 Policy #: MM166 Last Approval: 10/07/2020 Title: Transgender Health Policy Approved By: UM Medical Subcommittee
Line(s) of Business WAH-IMC (HCA) BHSO Medicare Advantage (CMS) Medicare SNP (CMS) Cascade Select
REQUIRED CLINICAL DOCUMENTATION FOR REVIEW
1. Clear documentation of the diagnosis of Gender Dysphoria must be provided. 2. Medical records required from all of the following: a) Two licensed mental health professionals (only one needed for Female to Male chest surgery) b) The medical provider who has managed the hormone therapy, primary care and/or transgender services c) The surgeon(s) recommending the surgical procedures 3. Clear evidence of a comprehensive, patient-centered plan of care with coordination between the care team and consent of the member must include the following: a) Plan of care documentation must include the member’s signature to document understanding of the treatment plan, surgical treatment, risks and benefits of the surgery; and b) A comprehensive referral letter for surgery, written and signed by a member of the treatment team, with a prior authorization request for surgery must be submitted to the plan. 4. Details of any specific needs related to risk/trauma/cultural etc.
BACKGROUND The category of Gender Affirming Surgery includes: 1. Breast/chest surgeries; 2. Genital surgeries; 3. Other surgeries.
Male-to-Female (MTF) affirming surgical procedures may include the following: 1. Breast/chest surgery: breast augmentation 2. Genital surgery: male genitalia to female genitalia include a penectomy (removal of penis) and orchiectomy (removal of the testes), which are typically followed by a vaginoplasty (creation of the vagina) or a feminizing genitoplasty (creation of female genitalia).
MM166_CCC_ Transgender Health Policy 1 of 7 DATA CONTAINED IN THIS DOCUMENT IS CONSIDERED CONFIDENTIAL AND PROPRIETARY INFORMATION AND ITS DUPLICATION USE OR DISCLOSURE IS PROHIBITED WITHOUT PRIOR APPROVAL OF COMMUNITY HEALTH PLAN OF WASHINGTON.
3. Other procedures: facial reconstruction surgery, electrolysis or laser hair removal, thyroid cartilage reduction, hair reconstruction, voice surgery.
Female-to-Male (FTM) gender affirming surgical procedures may include the following: 1. Breast/chest surgery: subcutaneous mastectomy, nipple grafts, chest reconstruction 2. Genital surgery: female genitalia to male genitalia incudes masculinizing genitoplasty (creation of male genitalia). The change to a masculine appearance may also include mastectomy and hysterectomy procedure. 3. Other procedures (rare): voice surgery
DEFINITIONS The following are synonyms: • Gender Affirming Surgery • Gender Confirming Surgery • Gender Reassignment Surgery • Gender Transition Surgery
Breast/chest surgeries: • Mammaplasty: surgical creation of the female breast. • Mastectomy: Surgical removal of the breast.
Genital surgeries: • Clitoroplasty: surgical creation of a clitoris. • Labiaplasty: surgical creation of the labia. • Hysterectomy: surgical removal of the uterus. • Metoidioplasty: female-to-male gender affirming surgery • Orchiectomy: surgical removal of the testes. • Penectomy: surgical removal of the penis. • Phalloplasty: surgical creation of a penis. • Prostatectomy: surgical removal of the prostate. • Salpingo-oophorectomy: surgical removal of the fallopian tubes and ovaries. • Scrotoplasty: surgical creation of a scrotum. • Urethroplasty: surgical creation of the urethra. • Vaginectomy: surgical removal of the vagina. • Vaginoplasty: surgical creation of a vagina. • Vulvectomy: surgical removal of the vulva. • Vulvoplasty: surgical creation of a vulva.
INDICATIONS/CRITERIA For CHPW AH-IMC Members: CHPW covers hormone therapy, electrolysis, mental health services and preventive services related to gender affirmation.
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Most surgical services are covered by fee-for-service, through the HCA. Prior Authorization by the Health Care Authority is required and CHPW is unable to facilitate the prior authorization process. https://www.hca.wa.gov/health-care-services-supports/apple-health-medicaid- coverage/transgender-health-program Transgender Health services may include, but are not limited to the following: • Breast reconstruction • Genital surgery • Electrolysis as required as part of the genital surgery • Hysterectomy • Mammoplasty with or without chest reconstruction • Metoidioplasty • Orchiectomy • Phalloplasty • Placement of testicular prosthesis
UM Process when Transgender Health Service request is received for CHPW AH-IMC Member: 1. Validate the request; 2. If the requested service is gender affirming surgery, contact the requesting provider and inform that these services are covered under HCA’s Fee-For-Service. Have the provider contact HCA. 3. Deny the requested service, and document in the adverse benefit notification that the services could be covered by the HCA as well as the contact information for HCA FFS for the prior authorization of the requested service. 4. Refer to Case Management.
For CHPW BHSO Members CHPW covers behavioral health services related to gender dysphoria and gender affirmation. Hormonal prescriptions and surgical services are covered through the member’s medical insurance. Prior Authorization for surgeries should be requested through the member’s medical insurance and CHPW is unable to facilitate the prior authorization.
For CHPW Medicare Members and CHNW Cascade Select Members: Hormone therapy, electrolysis, mental health services and preventive services related to gender affirmation are all covered. Criteria/Indications for Gender Affirming Surgery These criteria do not apply to members who are having these procedures for medical indications other than Gender Dysphoria.
Gender affirming surgery may be considered medically necessary in the treatment of gender dysphoria when all of the following criteria are met:
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1. Age at least 18 years. For members younger than 18 years of age, mastectomy may be considered medically necessary in female to male surgical procedures. Other requirements outlined in this Section must be met to proceed with surgery in those younger than 18 years of age.
2. Clinical records document that the member has the capacity to make fully informed decisions and consent for treatment, and as part of a comprehensive, patient-centered treatment plan; and that any other mental health condition, if present, is adequately controlled.
3. The multidisciplinary treatment team must have documented the diagnosis of gender dysphoria and recommend surgical treatment as part of a comprehensive, patient-centered plan of care. The plan of care and recommendation for surgical treatment must meet the criteria in A through D below.
a. The multidisciplinary treatment team consists of the following: two licensed mental health professionals*, the medical provider who has managed the hormone therapy and primary medical care and/or transgender services prior to surgical evaluation, and the surgeon(s) recommending the surgical procedures; and
*Only one mental health professional referral is required for mastectomy in female to males.
b. A surgical evaluation by a surgeon(s) who will perform the gender affirming surgery as part of a comprehensive, patient-centered plan of care. Upon completion, the surgeon must forward the results of the surgical evaluation and recommendations for surgical treatment to other treatment team members; and
c. Plan of care documentation must include the member’s signature to document understanding of the treatment plan, surgical treatment, risks and benefits of the surgery; and
d. A comprehensive referral letter for surgery, written and signed by a member of the treatment team, with a prior authorization request for surgery must be submitted to the plan.
4. One of the following regarding hormonal therapy and living in a gender congruent role: a) Documentation of continuous hormonal therapy and of living in a gender role that is congruent with the member’s gender identity for at least 12 months, i. Hormonal therapy is not required in the following situations: • The member has a documented contraindication to hormonal therapy; or • Prior to mastectomy for FTM gender affirmation
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b) If the referring medical provider or mental health provider requests gender affirming surgical intervention prior to the member’s completion of 12 months of hormone therapy and living in a gender role that is congruent with the member’s gender identity, the multidisciplinary treatment team must submit evidence of medical necessity and clear rationale for the proposed surgical intervention that includes all the following: i. A comprehensive, coordinated treatment plan with evidence that all treatment plan criteria for surgery and treatment goals have been met; and ii. Clear rationale for the variation from the 12-month period for either/or hormone therapy and living in a gender role that is congruent with the member’s gender identity; and iii. Documentation that the proposed surgical provider accepts the treatment plan and surgical intervention proposed by the coordinated clinical team’s treatment plan with less than 12 months living in a gender role that is congruent with the member’s gender identity and on hormone therapy; and iv. The member understands the treatment plan, risks and benefits of surgery prior to completing the 12-month period
For breast/chest surgeries: Hormone therapy is not a prerequisite for FTM patients. It is recommended that MTF patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery, unless clinically contraindicated.
Limitations of Coverage: • No surgery should be performed while a member is actively psychotic. • Excluded procedures include lipectomy of upper limbs, neck, and head; excision of excessive skin and subcutaneous tissue from abdomen, thigh, leg, hip, buttock, arm, forearm or hand. • Reversal of gender affirming surgery is not covered. • Storage of sperm, oocytes, or embryos is not covered.
SPECIAL CONSIDERATIONS All members requesting gender affirming surgical services will be referred to CHPW/CHNW Case Management to help with navigation and to ensure coordination of care.
LIMITATIONS/EXCLUSIONS Please refer to a product line’s certificate of coverage for benefit limitations and exclusions for these services:
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PRODUCT LINE LINK TO CERTIFICATE OF COVERAGE
Medicare Advantage https://medicare.chpw.org/chpw-washington- state-medicare-advantage-plans/all-medicare- plans-2020/
CHPW Apple Health - Integrated Managed Care https://www.chpw.org/for-members/benefits- and-coverage-imc/
CHPW BHSO https://www.chpw.org/for-members/benefits- and-coverage-imc/
Citations & References CFR WAC WAC 284-43-5642 Essential health benefit categories RCW Contract Citation WAH - IMC 17.1.10.21 General Description of Contracted Services: 11.4.6.1 For services that are excluded from (the WAH- IMC) Contract, but are covered by HCA, the Contractor’s denial will include directions to the Enrollee about how to obtain the services through HCA and will direct the Enrollee to those services and coordinate receipt of those services. BHSO 10.1 Utilization Management 13.1 Scope of Services MA Department of Health and Human Services DEPARTMENTAL APPEALS BOARD Appellate Division NCD 140.3, Transsexual Surgery Docket No. A-13-87 Decision No. 2576 May 30, 2014 Medicare Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, Effective January 1, 2020 Cascade Select WAC 284-43-5642 - Essential health benefit categories Other Requirements NCQA Elements UM 2, UM 5 References
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Revision History Revision Date Revision Description Revision Made By 07/19/2018 Original draft LuAnn Chen, MD 07/24/2018 Approved UM Medical Subcommittee 07/31/2019 Approved UM Committee 06/03/2019 Links checked. Reviewed, no changes. LuAnn Chen, MD Corrected the missed documentation of approval on 7/31/2019 by UM Committee 07/05/2019 Approval UM Medical Subcommittee 02/04/2020 Added list of Transgender Health services. Yves Houghton, RN Added how UM shall process requests when received. Updated MTF and FTM surgical procedures 02/12/2020 WAH-IMC and MA Contract Citations updated LuAnn Chen, MD 02/20/2020 Approval UM Medical Subcommittee 08/12/2020 Added referral to CM for AH-IMC members. LuAnn Chen, MD Added criteria for CHNW Cascade Select members. Clarified that all members requesting these services will be referred to CM. 09/10/2020 Approval UM Medical Subcommittee 10/05/2020 Clarified that AH-IMC members must receive Justin Fowler, RN a denial for non-covered surgical procedures. 10/06/2020 The changes are based on the WPATH LuAnn Chen, MD Standards of Care and Bree Collaborative LGBTQ Health Care Recommendations will be presented to CQIC on 10/13/2020 for potential adoption into Clinical Practice Guidelines: changed name of policy from Gender Transition Policy to Transgender Health Policy, changed terminology to gender affirming surgery, clarified coverage of electrolysis and preventive services related to gender affirmation. Added NCQA elements and formatting changes. 10/07/2020 Approval CMO Cabinet
MM166_CCC_ Transgender Health Policy 7 of 7 DATA CONTAINED IN THIS DOCUMENT IS CONSIDERED CONFIDENTIAL AND PROPRIETARY INFORMATION AND ITS DUPLICATION USE OR DISCLOSURE IS PROHIBITED WITHOUT PRIOR APPROVAL OF COMMUNITY HEALTH PLAN OF WASHINGTON.