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Aetna Aetna
Clinical Policy Bulletin:
Gender Reassignment Surgery
Number: 0615


Policy

Note: Most Aetna plans exclude coverage of gender reassignment surgery.  Please check benefit plan descriptions. 

Aetna considers gender reassignment surgery medically necessary when all of the following criteria are met:

  1. Requirements for mastectomy for female-to-male patients:

    1. Single letter of referral from a qualified mental health professional (see Appendix); and
    2. Persistent, well-documented gender dysphoria (see Appendix); and
    3. Capacity to make a fully informed decision and to consent for treatment; and
    4. Age of majority (18 years of age or older); and
    5. If significant medical or mental health concerns are present, they must be reasonably well controlled.

    Note that a trial of hormone therapy is not a pre-requisite to qualifying for a mastectomy.

  2. Requirements for gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male-to-female):

    1. Two referral letters from qualified mental health professionals, one in a purely evaluative role (see appendix); and
    2. Persistent, well-documented gender dysphoria (see Appendix); and
    3. Capacity to make a fully informed decision and to consent for treatment; and
    4. Age of majority (18 years or older); and
    5. If significant medical or mental health concerns are present, they must be reasonably well controlled; and
    6. Twelve months of continuous hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones)
       
  3. 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)

    1. Two referral letters from qualified mental health professionals, one in a purely evaluative role (see appendix); and
    2. Persistent, well-documented gender dysphoria (see Appendix); and
    3. Capacity to make a fully informed decision and to consent for treatment; and
    4. Age of majority (age 18 years and older); and
    5. If significant medical or mental health concerns are present, they must be reasonably well controlled; and
    6. Twelve months of continuous hormone therapy as appropriate to the member’s gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones); and
    7. Twelve months of living in a gender role that is congruent with their gender identity (real life experience).

Note: Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction thyroid chondroplasty, hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing, which have been used in feminization, are considered cosmetic. Similarly, chin implants, nose implants, and lip reduction, 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:

  1. Breast cancer screening may be medically necessary for female to male trans identified persons who have not undergone a mastectomy;
  2. Prostate cancer screening may be medically necessary for male to female trans identified persons who have retained their prostate.

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):

  • Abdominoplasty
  • Blepharoplasty
  • Brow lift
  • Calf implants
  • Cheek/malar implants
  • Chin/nose implants
  • Collagen injections
  • Construction of a clitoral hood
  • Drugs for hair loss or growth
  • Forehead lift
  • Hair removal
  • Hair transplantation
  • Lip reduction
  • Liposuction
  • Mastopexy
  • Neck tightening
  • Pectoral implants
  • Removal of redundant skin
  • Rhinoplasty
  • Voice therapy/voice lessons.


Background

Transsexualism is a gender identity condition "in which the person manifests, with constant and persistent conviction, the desire to live as a member of the opposite sex and progressively take steps to live in the opposite sex role full-time."  People who wish to change their sex may be referred to as "Transsexuals" or as people suffering from "gender dysphoria" (meaning unhappiness with one's gender).

For male to female trans identified individuals selected for surgery, procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty), breast augmentation and cosmetic surgery (facial reshaping, rhinoplasty, abdominoplasty, laryngeal shaving, vocal cord shortening, hair transplants) (Day, 2002). For female to male trans identified individuals, surgical procedures may include genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, chest wall contouring and cosmetic surgery (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.

Appendix

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:

  1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics)
  2. 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 (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
  3. A strong desire for the primary and/or secondary sex characteristics of the other gender
  4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
  5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
  6. 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.

Table 2: Format for referral letters from Qualified Health Professional: (From SOC-7)

  1. Client’s general identifying characteristics; and
  2. Results of the client’s psychosocial assessment, including any diagnoses; and
  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
  4. An explanation that the WPATH criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery; and
  5. A statement about the fact that informed consent has been obtained from the patient; and
  6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

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):

  1. Master’s degree or equivalent in a clinical behavioral science field granted by an institution accredited by the appropriate national accrediting board.  The professional should also have documented credentials from the relevant licensing board or equivalent; and
  2. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Disease for diagnostic purposes; and
  3. Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria; and
  4. Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria; and
  5. Continuing education in the assessment and treatment of gender dysphoria.  This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria. 
 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
19301, 19303 - 19304
53430
54125
54400 - 54417
54520
54660
54690
55175
55180
55970
55980
56625
56800
56805
56810
57106 - 57107, 57110 - 57111
57291 - 57292
57335
58150, 58180, 58260 - 58262, 58275 - 58291, 58541 - 58544, 58550 - 58554
58570 - 58573
58661
58720
CPT codes not covered for indications listed in the CPB [considered cosmetic]:
11950 - 11954
15775
15776
15780 - 15787
15788 - 15793
15820 - 15823
15824 - 15828
15830 - 15839
15876 - 15879
17380
19316
19318
19324 - 19325
19340
19342
19350
21120 - 21123
21125 - 21127
21208
21210
21270
30400 - 30420
30430 - 30450
67900
92507
92508
Other CPT codes related to the CPB:
11980
90785
90832 - 90838
96372
HCPCS codes covered if selection criteria are met:
J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg
J9217 Leuprolide acetate (for depot suspension), 7.5 mg
J9218 Leuprolide acetate, per 1 mg
J9219 Leuprolide acetate implant, 65 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-9 codes covered if selection criteria are met:
302.50 - 302.53 Trans-sexualism
302.85 Gender identity disorder in adolescents or adults
ICD-9 codes not covered for indications listed in the CPB:
293.0 - 302.4, 302.6 - 302.84, 302.89 - 319 Mental disorders [other than transexualism and gender identity disorder]
752.7 Indeterminate sex and pseudohermaphroditism
758.0 - 758.9 Chromosomal anomalies


The above policy is based on the following references:
  1. Becker S, Bosinski HA, Clement U, et al. Standards for treatment and expert opinion on transsexuals. The German Society for Sexual Research, The Academy of Sexual medicine and the Society for Sexual Science. Fortschr Neurol Psychiatr. 1998;66(4):164-169.
  2. Landen M, Walinder J, Lundstrom B. Clinical characteristics of a total cohort of female and male applicants for sex reassignment: A descriptive study. Acta Psychiatr Scand. 1998;97(3):189-194.
  3. Schlatterer K, Yassouridis A, von Werder K, et al. A follow-up study for estimating the effectiveness of a cross-gender hormone substitution therapy on transsexual patients. Arch Sex Behav. 1998;27(5):475-492.
  4. Midence K, Hargreaves I. Psychosocial adjustment in male-to-female transsexuals: An overview of the research evidence. J Psychol. 1997;131(6):602-614.
  5. van Kesteren PJ, Asscheman H, Megens JA, et al. Mortality and morbidity in transsexual subjects treated with cross-sex hormones. Clin Endocrinol (Oxf). 1997;47(3):337-342.
  6. Eldh J, Berg A, Gustafsson M. Long-term follow up after sex reassignment surgery. Scand J Plast Reconstr Surg Hand Surg. 1997;31(1):39-45.
  7. Bradley SJ, Zucker KJ. Gender identity disorder: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1997;36(7):872-880.
  8. Luton JP, Bremont C. The place of endocrinology in the management of transsexualism. Bull Acad Natl Med. 1996;180(6):1403-1407.
  9. Beemer BR. Gender dysphoria update. J Psychosoc Nurs Ment Health Serv. 1996;34(4):12-19.
  10. Schlatterer K, von Werder K, Stalla GK. Multistep treatment concept of transsexual patients. Exp Clin Endocrinol Diabetes. 1996;104(6):413-419.
  11. Breton J, Cordier B. Psychiatric aspects of transsexualism. Bull Acad Natl Med. 1996;180(6):1389-1393; discussion 1393-1394.
  12. Hage JJ. Medical requirements and consequences of sex reassignment surgery. Med Sci Law. 1995;35(1):17-24.
  13. Cole CM, Emory LE, Huang T, et al. Treatment of gender dysphoria (transsexualism). Tex Med. 1994;90(5):68-72.
  14. Snaith RP, Hohberger AD. Transsexualism and gender reassignment. Br J Psychiatry. 1994;165(3):418-419.
  15. Cohen-Kettenis PT, Kuiper AJ, Zwaan WA, et al. Transsexualism. II. Diagnosis: The initial, tentative phase. Ned Tijdschr Geneeskd. 1992;136(39):1895-1897.
  16. Brown GR. A review of clinical approaches to gender dysphoria. J Clin Psychiatry. 1990;51(2):57-64.
  17. Mate-Kole C. Sex reassignment surgery. Br J Hosp Med. 1989;42(4):340.
  18. Gooren LJ. Transsexualism. I. Description, etiology, management. Ned Tijdschr Geneeskd. 1992;136(39):1893-1895.
  19. Petersen ME, Dickey R. Surgical sex reassignment: A comparative survey of international centers. Arch Sex Behav. 1995;24(2):135-156.
  20. Alberta Heritage Foundation for Medical Research (AHFMR). Phalloplasty in female-male transsexuals. Technote TN 6. Edmonton, AB: AHFMR; 1996. Available at: http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?View=Full&ID=31998008919. Accessed June 30, 2010.
  21. Alberta Heritage Foundation for Medical Research (AHFMR). Vaginoplasty in male-female transsexuals and criteria for sex reassignment surgery. Technote TN 7. Edmonton, AB: AHFMR; 1997. Available at: http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?ID=31998008920. Accessed June 30, 2010.
  22. Best L, Stein K. Surgical gender reassignment for male to female transsexual people. DEC Report No. 88. Southampton, UK: Wessex Institute for Health Research and Development, University of Southampton; 1998. Available at: http://www.hta.ac.uk/rapidhta/publications/dec88.pdf. Accessed June 30, 2010.
  23. Smith YL, Cohen L, Cohen-Kettenis PT. Postoperative psychological functioning of adolescent transsexuals: A Rorschach study. Arch Sex Behav. 2002;31(3):255-261.
  24. Day P. Trans-gender reassignment surgery. NZHTA Tech Brief Series. Christchurch, New Zealand: New Zealand Health Technology Assessment (NZHTA); 2002;1(1). Available at: http://nzhta.chmeds.ac.nz/publications/trans_gender.pdf. Accessed June 30, 2010.
  25. Lawrence AA, Latty EM, Chivers ML, Bailey JM. Measurement of sexual arousal in postoperative male-to-female transsexuals using vaginal photoplethysmography. Arch Sex Behav. 2005;34(2):135-145.
  26. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003;32(4):299-315.
  27. Tugnet N, Goddard JC, Vickery RM, et al.  Current management of male-to-female gender identity disorder in the UK. Postgrad Med J. 2007;83(984):638-642.
  28. Sutcliffe PA, Dixon S, Akehurst RL, et al. Evaluation of surgical procedures for sex reassignment: A systematic review. J Plast Reconstr Aesthet Surg. 2009;62(3):294-306; discussion 306-308.
  29. Tønseth KA, Bjark T, Kratz G, et al. Sex reassignment surgery in transsexuals. Tidsskr Nor Laegeforen. 2010;130(4):376-379.
  30. Hembree et al. Endocrine Treatment of Transsexual Persons:  An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2009; 94(9):3132-3154.
  31. Meriggiola MC, Jannini EA, Lenzi A, et al. Endocrine treatment of transsexual persons: An Endocrine Society Clinical Practice Guideline: Commentary from a European perspective. Eur J Endocrinol. 2010;162(5):831-833.
  32. UK National Health Service (NHS), Oxfordshire Primary Care Trust, South Central Priorities Committee. Treatments for gender dysphoria. Policy Statement 18c. Ref TV63. Oxford, UK: NHS; updated September 2009.
  33. Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgend. 2011;13:165-232.
  34. Byne W, Bradley SJ, Coleman E, et al.; American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Arch Sex Behav. 2012;41(4):759-796.
  35. Coleman E, Adler R, Bockting W, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Version 7. Minneapolis, MN: World Professional Association for Transgender Health (WPATH); 2011. Available at: http://www.wpath.org/publications_standards.cfm. Accessed August 28, 2013.
  36. Nakatsuka M. [Adolescents with gender identity disorder: Reconsideration of the age limits for endocrine treatment and surgery]. Seishin Shinkeigaku Zasshi. 2012;114(6):647-653.
  37. Spack NP. Management of transgenderism. JAMA. 2013;309(5):478-484.
  38. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  39. Leinung MC, Urizar MF, Patel N, Sood SC. Endocrine treatment of transsexual persons: Extensive personal experience. Endocr Pract. 2013;19(4):644-650.
  40. Meyer-Bahlburg HF. Sex steroids and variants of gender identity. Endocrinol Metab Clin North Am. 2013;42(3):435-452.
  41. Gooren LJG, Tangpricha V. Treatment of transsexualism. UpToDate [serial online]. Waltham, MA: UpToDate; reviewed April 2014.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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