Aetna considers gender reassignment surgery medically necessary when all of the following criteria are met:
Requirements for mastectomy for female-to-male patients:
Note that a trial of hormone therapy is not a pre-requisite to qualifying for a mastectomy.
Requirements for gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male-to-female):
Requirements for genital reconstructive surgery (i.e., vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular prosthesis and erectile prosthesis in female to male; penectomy, vaginoplasty, labiaplasty, and clitoroplasty in male to female)
Note: Blepharoplasty, body contouring (liposuction of the waist), breast enlargement procedures such as augmentation mammoplasty and implants, face-lifting, facial bone reduction, feminization of torso, hair removal, lip enhancement, reduction thyroid chondroplasty, rhinoplasty, skin resurfacing (dermabrasion, chemical peel), and voice modification surgery (laryngoplasty, cricothyroid approximation or shortening of the vocal cords), which have been used in feminization, are considered cosmetic. Similarly, chin implants, lip reduction, masculinization of torso, and nose implants, which have been used to assist masculinization, are considered cosmetic.
Note on gender specific services for the transgender community:
Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy. Examples include:
Aetna considers gonadotropin-releasing hormone medically necessary to suppress puberty in trans identified adolescents if they meet World Professional Association for Transgender Health (WPATH) criteria (see CPB 501 - Gonadotropin-Releasing Hormone Analogs and Antagonists).
Aetna considers the following procedures that may be performed as a component of a gender reassignment as cosmetic (not an all-inclusive list) (see also CPB 0031 - Cosmetic Surgery):
Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between an individual’s gender identity and the gender assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). 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, and it must continue for at least six months. This condition may cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
Gender reassignment surgery is performed to change primary and/or secondary sex characteristics. For male to female gender reassignment, surgical procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty) and cosmetic surgery (breast implants, facial reshaping, rhinoplasty, abdominoplasty, thyroid chondroplasty (laryngeal shaving), voice modification surgery (vocal cord shortening), hair transplants) (Day, 2002). For female to male gender reassignment, surgical procedures may include mastectomy, genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, and cosmetic procedures to enhance male features such as pectoral implants and chest wall recontouring (Day, 2002).
The criterion noted above for some types of genital surgeries – i.e., that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity – is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery (Coleman, et al., 2011).
In addition to hormone therapy and gender reassignment surgery, psychological adjustments are necessary in affirming sex. Treatment should focus on psychological adjustment, with hormone therapy and gender reassignment surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Mental health care may need to be continued after gender reassignment surgery. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the trans identified person and the support from family, friends, employers and the medical profession.
Nakatsuka (2012) noted that the 3rd versions of the guideline for treatment of people with gender dysphoria (GD) of the Japanese Society of Psychiatry and Neurology recommends that feminizing/masculinizing hormone therapy and genital surgery should not be carried out until 18 years old and 20 years old, respectively. On the other hand, the 6th (2001) and the 7th (2011) versions of the standards of care for the health of transsexual, transgender, and gender non-conforming people of World Professional Association for Transgender Health (WPATH) recommend that transgender adolescents (Tanner stage 2, [mainly 12 to 13 years of age]) are treated by the endocrinologists to suppress puberty with gonadotropin-releasing hormone (GnRH) agonists until age 16 years old, after which cross-sex hormones may be given. A questionnaire on 181 people with GID diagnosed in the Okayama University Hospital (Japan) showed that female to male (FTM) trans identified individuals hoped to begin masculinizing hormone therapy at age of 15.6 +/- 4.0 (mean +/- S.D.) whereas male to female (MTF) trans identified individuals hoped to begin feminizing hormone therapy as early as age 12.5 +/- 4.0, before presenting secondary sex characters. After confirmation of strong and persistent trans gender identification, adolescents with GD should be treated with cross-gender hormone or puberty-delaying hormone to prevent developing undesired sex characters. These treatments may prevent transgender adolescents from attempting suicide, suffering from depression, and refusing to attend school.
Spack (2013) stated that GD is poorly understood from both mechanistic and clinical standpoints. Awareness of the condition appears to be increasing, probably because of greater societal acceptance and available hormonal treatment. Therapeutic options include hormone and surgical treatments but may be limited by insurance coverage because costs are high. For patients seeking MTF affirmation, hormone treatment includes estrogens, finasteride, spironolactone, and GnRH analogs. Surgical options include feminizing genital and facial surgery, breast augmentation, and various fat transplantations. For patients seeking a FTM gender affirmation, medical therapy includes testosterone and GnRH analogs and surgical therapy includes mammoplasty and phalloplasty. Medical therapy for both FTM and MTF can be started in early puberty, although long-term effects are not known. All patients considering treatment need counseling and medical monitoring.
Leinung and colleagues (2013) noted that the Endocrine Society's recently published clinical practice guidelines for the treatment of transgender persons acknowledged the need for further information on transgender health. These investigators reported the experience of one provider with the endocrine treatment of transgender persons over the past 2 decades. Data on demographics, clinical response to treatment, and psychosocial status were collected on all transgender persons receiving cross-sex hormone therapy since 1991 at the endocrinology clinic at Albany Medical Center, a tertiary care referral center serving upstate New York. Through 2009, a total 192 MTF and 50 FTM transgender persons were seen. These patients had a high prevalence of mental health and psychiatric problems (over 50 %), with low rates of employment and high levels of disability. Mental health and psychiatric problems were inversely correlated with age at presentation. The prevalence of gender reassignment surgery was low (31 % for MTF). The number of persons seeking treatment has increased substantially in recent years. Cross-sex hormone therapy achieves very good results in FTM persons and is most successful in MTF persons when initiated at younger ages. The authors concluded that transgender persons seeking hormonal therapy are being seen with increasing frequency. The dysphoria present in many transgender persons is associated with significant mood disorders that interfere with successful careers. They stated that starting therapy at an earlier age may lessen the negative impact on mental health and lead to improved social outcomes.
Meyer-Bahlburg (2013) summarized for the practicing endocrinologist the current literature on the psychobiology of the development of gender identity and its variants in individuals with disorders of sex development or with transgenderism. Gender reassignment remains the treatment of choice for strong and persistent gender dysphoria in both categories, but more research is needed on the short-term and long-term effects of puberty-suppressing medications and cross-sex hormones on brain and behavior.
Table 1: DSM 5 Criteria for Gender Dysphoria in Adults and Adolecents:.
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by two or more of the following:
B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Table 2: Format for referral letters from Qualified Health Professional: (From SOC-7)
Note: There is no minimum duration of relationship required with mental health professional. It is the professional’s judgment as to the appropriate length of time before a referral letter can appropriately be written. A common period of time is three months, but there is significant variation in both directions. When two letters are required, the second referral is intended to be an evaluative consultation, not a representation of an ongoing long-term therapeutic relationship, and can be written by a medical practitioner of sufficient experience with gender dysphoria.
Note: Evaluation of candidacy for sex reassignment surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. Please check benefit plan descriptions.
Table 3: Characteristics of a Qualified Mental Health Professional: (From SOC-7):
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|19301, 19303 - 19304||Mastectomy|
|53430||Urethroplasty, reconstruction of female urethra|
|54125||Amputation of penis; complete|
|54400 - 54417||Penile prosthesis|
|54520||Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach|
|54660||Insertion of testicular prosthesis (separate procedure)|
|54690||Laparoscopic, surgical; orchiectomy|
|55970||Intersex surgery; male to female [a series of staged procedures that includes male genitalia removal, penile dissection, urethral transposition, creation of vagina and labia with stent placement]|
|55980||female to male [a series of staged procedures that include penis and scrotum formation by graft, and prostheses placement]|
|56625||Vulvectomy simple; complete|
|56800||Plastic repair of introitus|
|56805||Clitoroplasty for intersex state|
|56810||Perineoplasty, repair of perineum, nonobstetrical (separate procedure)|
|57106 - 57107, 57110 - 57111||Vaginectomy|
|57291 - 57292||Construction of artificial vagina|
|57335||Vaginoplasty for intersex state|
|58150, 58180, 58260 - 58262, 58275 - 58291, 58541 - 58544, 58550 - 58554||Hysterectomy|
|58570 - 58573||Laparoscopy, surgical, with total hysterectomy|
|58661||Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)|
|58720||Salpingo-oophorectomy, complete or partial, unilateral or bilateral|
|CPT codes not covered for indications listed in the CPB [considered cosmetic]:|
|11950 - 11954||Subcutaneous injection of filling material (e.g., collagen)|
|15775||Punch graft for hair transplant; 1 to 15 punch grafts|
|15776||Punch graft for hair transplant; more than 15 punch grafts|
|15780 - 15787||Dermabrasion|
|15788 - 15793||Chemical peel|
|15820 - 15823||Blepharoplasty|
|15824 - 15828||Rhytidectomy [face-lifting]|
|15830 - 15839||Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy|
|15876 - 15879||Suction assisted lipectomy|
|17380||Electrolysis epilation, each 30 minutes|
|19324 - 19325||Mammaplasty, augmentation|
|19340||Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction|
|19342||Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction|
|21120 - 21123||Genioplasty|
|21125 - 21127||Augmentation, mandibular body or angle; prosthetic material or with bone graft, onlay or interpositional (includes obtaining autograft)|
|21193||Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft|
|21194||with bone graft (includes obtaining graft)|
|21195||Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation|
|21196||with internal rigid fixation|
|21208||Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)|
|21210||Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)|
|21270||Malar augmentation, prosthetic material|
|30400 - 30420||Rhinoplasty; primary|
|30430 - 30450||Rhinoplasty; secondary|
|67900||Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)|
|92507||Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual|
|92508||Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, two or more individuals|
|Other CPT codes related to the CPB:|
|11980||Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)|
|+90785||Interactive complexity (List separately in addition to the code for primary procedure)|
|90832 - 90838||Psychotherapy|
|96372||Therapeutic, prophylactic, or diagnostic injection (specify substance of drug); subcutaneous or intramuscular|
|HCPCS codes covered if selection criteria are met:|
|C1813||Prosthesis, penile, inflatable|
|C2622||Prosthesis, penile, non-inflatable|
|J1950||Injection, leuprolide acetate (for depot suspension), per 3.75 mg|
|J9202||Goserelin acetate implant, per 3.6 mg|
|J9217||Leuprolide acetate (for depot suspension), 7.5 mg|
|J9218||Leuprolide acetate, per 1 mg|
|J9219||Leuprolide acetate implant, 65 mg|
|S0189||Testosterone pellet, 75 mg|
|HCPCS codes not covered for indications listed in the CPB :|
|G0153||Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes|
|S9128||Speech therapy, in the home, per diem|
|ICD-10 codes covered if selection criteria are met:|
|F64.0 - F64.1||Gender identity disorder in adolescences and adulthood|
|Z87.890||Personal history of sex reassignment|
|ICD-10 codes not covered for indications listed in the CPB:|
|F01.50 - F63.9, F64.2 - F99||Mental disorders [other than adult gender identity disorder]|
|Q56.0 - Q56.4||Indeterminate sex and pseudohermaphroditism|
|Q90.0 - Q99.9||Chromosomal anomalies, not elsewhere classified|
|R37||Sexual dysfunction, unspecified|