CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Gender Reassignment Surgery

Policy documents coverage and guidelines for gender reassignment surgery (GRS) for BlueCHiP for Medicare and Commercial products, including required eligibility documentation, prior authorization requirements, and lists of medically necessary procedures for transwomen and transmen when benefit exists.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Gender Reassignment Surgery

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2016

Next Review Date

Key ActionObtain prior authorization for BlueCHiP for Medicare and submit required comprehensive evaluation and surgeon documentation to establish eligibility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

12Named surgical procedures listed

2CPT codes explicitly excluded from pricing

12Real-life experience requirement (months)

Coverage Summary

This policy covers Gender Reassignment Surgery (GRS) for BlueCHiP for Medicare and Commercial products and is currently effective 2016-07-01 with last update 2018-07-03. Coverage stance is mixed: when a benefit exists and documentation and eligibility criteria are met, a list of GRS procedures is considered medically necessary for transwomen and transmen; cosmetic procedures remain excluded depending on product. Prior authorization is required for BlueCHiP for Medicare and recommended for Commercial groups to determine eligibility and benefits. The policy reflects real-life experience and hormone therapy prerequisites, requiring 12 months of full-time living and working in the desired gender role (real-life experience) and 12 continuous months of hormone therapy prior to considering surgery.

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Medical-Necessity Criteria

Eligibility / Medical Necessity Criteria for Gender Reassignment Surgery

Covered when ALL of the following are met:

ALL of the following

The individual has been diagnosed with the gender identity disorder (GID) or gender dysphoria of transsexualism.
The individual has successfully lived and worked within the desired role full-time for at least 12 months (real-life experience) without returning to the original gender.12 months
Documentation requirement
- Letters that attest to the psychological aspects of the candidate's GID.
- One letter from the candidate's physician or behavioral health provider who has treated the candidate for a minimum of 12 months (or combined treatment from two clinicians totaling 12 months).12 months
- One letter from a behavioral health professional with a doctoral degree capable of evaluating co-morbid psychiatric conditions.
- If letters in 1a and 1b come from the same clinician, an additional corroborating letter from a second physician or behavioral health provider is required.
- Letter of documentation from the treating surgeon confirming eligibility criteria, that the surgeon has personally communicated with the treating mental health provider/physician, that the surgeon feels the candidate is likely to benefit, and that the candidate understands the ramifications of surgery.
Letter content requirements
- Whether letter author is part of an identity disorder treatment team.
- Candidate's general identifying characteristics.
- Initial and evolving gender, sexual, and other psychiatric diagnoses.
- Duration of professional relationship and type of psychotherapy or evaluation undergone.
- Which eligibility criteria have been met by the candidate.
- Physician or mental health professional's rationale for surgery.

Medically Necessary Surgeries when Benefit Exists - Transwomen (male to female)

When a covered benefit exists and eligibility criteria are met, the following are considered medically necessary:

ALL of the following

Orchiectomy
Penectomy
Vaginoplasty
Colovaginoplasty
Clitoroplasty
Labiaplasty

Medically Necessary Surgeries when Benefit Exists - Transmen (female to male)

When a covered benefit exists and eligibility criteria are met, the following are considered medically necessary:

ALL of the following

Breast reconstruction
Reduction mammoplasty
Hysterectomy
Salpingo-oophorectomy
Colpectomy/Vaginectomy
Metoidioplasty

Exclusions / Cosmetic Procedures

Cosmetic exclusions by product:

ANY of the following

Commercial: For Commercial products: procedures considered cosmetic are not covered; refer to cosmetic policy for list of services.
BlueCHiP for Medicare: For BlueCHiP for Medicare: cosmetic surgery or expenses incurred in connection with such surgery is not covered; cosmetic surgery defined as any surgical procedure directed at improving appearance, except when required for prompt repair of accidental injury or for improvement of function of a malformed body member.

Prior Authorization & Provider Requirements

Prior Authorization

Preauthorization requirements by product:

ALL of the following

Prior authorization is required for BlueCHiP for Medicare.
Prior authorization is recommended for Commercial groups.
Preauthorization is used to determine eligibility for coverage and to assist in maximizing the benefit.

Prior Authorization

Obtain prior authorization for BlueCHiP for Medicare

Prior authorization is required for members covered under BlueCHiP for Medicare. For Commercial products, prior authorization is recommended to determine eligibility and benefits and to assist in maximizing the benefit.

Prior authorization is required for BlueCHiP for Medicare.
Prior authorization is recommended for Commercial groups.
Preauthorization is used to determine eligibility for coverage and to assist in maximizing the benefit.

Documentation Required

Submit comprehensive evaluation letters

Submit comprehensive evaluation letters that document diagnosis, duration of care (minimum 12 months of treatment by the treating clinician or combined clinicians), a behavioral health evaluation, and treating surgeon documentation as required by policy.

Letter(s) attesting to the psychological aspects of the candidate’s GID/gender dysphoria.
One letter from the candidate’s physician or behavioral health provider who has treated the candidate for a minimum of 12 months (or combined clinicians totaling 12 months if care transferred).
One letter from a behavioral health professional with a doctoral degree able to evaluate co-morbid psychiatric conditions.
If the treating clinician authored both required letters, an additional corroborating letter from a second physician or behavioral health provider is required.
Letters must document whether the author is part of an identity disorder treatment team, candidate’s identifying characteristics, initial and evolving diagnoses, duration and type of professional relationship, which eligibility criteria have been met, and the author’s rationale for surgery.
Letters must address the degree to which the candidate has followed treatment and experiential requirements, participation in psychotherapy during the 12-month real-life trial (if recommended), and ability to function in the desired gender role.
Letters should document progress consolidating new gender identity and satisfactory control of behavioral health issues (e.g., substance abuse, psychosis, suicidality).
A letter of documentation must be received from the treating surgeon (see surgeon-specific requirements).

Documentation Required

Surgeon communication requirement

The treating surgeon must personally communicate with the treating mental health provider or physician and provide a letter confirming that the surgeon has communicated with the mental health provider, believes the candidate is likely to benefit from surgery, and has personally communicated with the candidate that they understand the ramifications of surgery.

Surgeon letter must confirm the candidate meets the policy eligibility criteria.
Surgeon must have personally communicated with the treating mental health provider or physician.
Surgeon must state that they feel the candidate is likely to benefit from surgery.
Surgeon must confirm they personally communicated with the candidate and that the candidate understands the ramifications of surgery.

Billing Rule

Do not bill using generic intersex CPT codes 55970/55980

Do not use CPT 55970 or 55980 for pricing or claims processing. These generic intersex procedure codes are not to be used; file claims with the specific procedure CPT codes that describe the performed service.

55970
55980
Use specific CPT procedure codes instead of 55970/55980.

Background & Evidence

Gender identity disorder (GID) / gender dysphoria is the diagnostic context for this policy; DSM terminology has evolved to use gender dysphoria, and the policy references WPATH and Endocrine Society guidance. The policy states that GRS is not a single procedure but part of a complex process involving multiple medical, psychiatric, and surgical modalities and that candidates require medical and psychological evaluations before surgery.

Typical prerequisites include hormone replacement therapy of 12 continuous months (testosterone for transmen; anti-androgens and estrogens for transwomen) and a period of real-life experience living and working full-time in the desired gender role for at least 12 months prior to irreversible surgical interventions.

The policy requires comprehensive evaluation documentation (letters) from treating physicians and behavioral health professionals attesting to diagnosis, duration of care (minimum combined or single clinician treatment totaling 12 months), ability to function in the desired role, management of co-morbid psychiatric conditions, and surgeon confirmation of communication with behavioral health providers and that the candidate understands the ramifications of surgery.

Evidence and guideline support include the Endocrine Society clinical practice guideline (Hembree et al., 2009), which recommends that surgery be considered only after both the physician responsible for endocrine transition therapy and the mental health professional find surgery advisable, that surgery be recommended only after completion of at least one year of consistent and compliant hormone treatment, and that sex reassignment surgical procedures be recommended only after a comprehensive evaluation by a qualified mental health professional.

The policy specifies comprehensive evaluation documentation: letters attesting to psychological aspects of GID, one letter from the treating physician or behavioral health provider with at least 12 months of treatment (or combined clinicians totaling 12 months), one letter from a doctoral-level behavioral health professional able to evaluate co-morbid psychiatric conditions, and a surgeon’s letter confirming eligibility criteria, communication with treating mental health providers, that the surgeon believes the candidate will benefit, and that the candidate understands surgical ramifications.

Definitions

Real-life experienceLiving and working full-time in the desired gender role for at least 12 months without returning to the original gender

Cosmetic surgery (Medicare)Any surgical procedure directed at improving appearance, except for prompt repair of accidental injury or for improvement of function of a malformed body member

OpenPayer

Medical Coverage Policy Gender Reassignment Surgery

Coverage Summary

Medical-Necessity Criteria

Prior Authorization & Provider Requirements

Coding

Background & Evidence

Revision History

55970	Intersex surgery; male to female
55980	Intersex surgery; female to male