Clinical UM Guideline


Subject:Gender Reassignment Surgery
Guideline #:  CG-SURG-27Current Effective Date:  10/08/2013
Status:RevisedLast Review Date:  08/08/2013

Description

Gender reassignment surgery is one treatment option for extreme cases of gender dysphoria, a condition in which a person feels a strong and persistent identification with the opposite gender accompanied with a severe sense of discomfort in their own gender.  People with gender dysphoria often report a feeling of being born the wrong sex.  Gender reassignment surgery is not a single procedure, but part of a complex process involving multiple medical, psychiatric, and surgical specialists working in conjunction with each other and the individual to achieve successful behavioral and medical outcomes.  Before undertaking gender reassignment surgery, important medical and psychological evaluations, medical therapies and behavioral trials should be undertaken to confirm that surgery is the most appropriate treatment choice for the individual.

Please refer to the following documents for additional information:

Clinical Indications

Medically Necessary: 

For individuals undergoing gender reassignment surgery*, consisting of any combination of the following; hysterectomy, salpingo-oophorectomy; ovariectomy, or orchiectomy, are considered medically necessary when all of the following criteria are met:

  1. The individual is at least 18 years of age; and
  2. The individual has capacity to make fully informed decisions and consent for treatment; and
  3. The individual has been diagnosed with gender dysphoria, and exhibits  all of the following:
    1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
    2. The transsexual identity has been present persistently for at least two years; and
    3. The disorder is not a symptom of another mental disorder; and
    4. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and
  4. Individuals without a medical contraindication or otherwise unable or unwilling to take hormones, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and
  5. If the individual has significant medical or mental health issues present, they must be reasonably well controlled.  If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
  6. Two referrals from qualified mental health professionals who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (e.g., if practicing within the same clinic) are required.

For individuals undergoing gender reassignment surgery*, consisting of any combination of the following; metoidioplasty, phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, or placement of testicular prostheses, are considered medically necessary when all of the following criteria are met:

  1. The individual is at least 18 years of age; and
  2. The individual has capacity to make fully informed decisions and consent for treatment; and
  3. The individual has been diagnosed with gender dysphoria and exhibits all of the following:
    1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
    2. The transsexual identity has been present persistently for at least two years; and
    3. The disorder is not a symptom of another mental disorder; and
    4. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and
  4. Individuals without a medical contraindication or otherwise unable or unwilling to take hormones, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and
  5. Documentation that the individual has completed a minimum of 12 months of successful continuous full time real-life experience in their new gender, across a wide range of life experiences and events that may occur throughout the year (e.g., family events, holidays, vacations, season-specific work or school experiences).  This includes coming out to partners, family, friends, and community members (e.g., at school, work, other settings).
    Note:
    • The medical documentation should include the start date of living full time in the new gender.
    • Verification via communication with individuals who have related to the individual in an identity-congruent gender role, or requesting documentation of a legal name change, may be reasonable in some cases; and
  6. Regular participation in psychotherapy throughout the real-life experience when recommended by a treating medical or behavioral health practitioner; and
  7. If the individual has significant medical or mental health issues present, they must be reasonably well controlled.  If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
  8. Two referrals from qualified mental health professionals who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (e.g., if practicing within the same clinic) are required.

** At least one of the professionals submitting a letter must have a doctoral degree (Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D) and be capable of adequately evaluating co-morbid psychiatric conditions. One letter is sufficient if signed by two providers, one of whom has met the doctoral degree specifications, in addition to the specifications set forth above.

Not Medically Necessary: 

Gender reassignment surgery is considered not medically necessary when one or more of the criteria above have not been met.

Cosmetic:

The following surgeries are considered cosmetic when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender reassignment surgery:

  1. Reduction thyroid chondroplasty
  2. Liposuction
  3. Rhinoplasty
  4. Facial bone reconstruction
  5. Face lift
  6. Blepharoplasty
  7. Voice modification surgery
  8. Hair removal/hairplasty
  9. Breast augmentation
Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
55970Intersex surgery; male to female
55980Intersex surgery; female to male
  
 Also combinations of  individual procedures billed separately, including but not limited to
19325Mammaplasty, augmentation; with prosthetic implant
54125Amputation of penis; complete
54520Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach
54660Insertion of testicular prosthesis
54690Laparoscopy, surgical; orchiectomy
55180Scrotoplasty; complicated
56625Vulvectomy, simple; complete
56800Plastic repair of introitus
56805Clitoroplasty for intersex state
57110Vaginectomy, complete removal of vaginal wall;
57291Construction of artificial vagina; without graft
57292Construction of artificial vagina; with graft
57295Revision (including removal) of prosthetic vaginal graft; vaginal approach
57296Revision (including removal) of prosthetic vaginal graft; open abdominal approach
57426Revision (including removal) of prosthetic vaginal graft, laparoscopic approach
58150Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);
58552Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s)
58554Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s)
58571Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58573Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
  
ICD-9 Procedure 
62.41Removal of both testes at same operative episode
62.7Insertion of testicular prosthesis
64.3Amputation of penis
64.43Construction of penis
64.5Operations for sex transformation, not elsewhere classified
65.61Other removal of both ovaries and tubes at same operative session
65.63Laparoscopic removal of both ovaries and tubes at the same operative episode
68.41-68.49Total abdominal hysterectomy
68.51Laparoscopically assisted vaginal hysterectomy (LAVH)
68.59Other vaginal hysterectomy
70.4Obliteration and total excision of vagina
70.61Vaginal construction
71.4Operations on clitoris
71.62Bilateral vulvectomy
  
ICD-9 Diagnosis 
302.50-302.53Trans-sexualism
302.6Gender identity disorder in children or NOS
302.85Gender identity disorder in adolescents or adults
  
ICD-10 ProcedureICD-10-PCS draft codes; effective 10/01/2014:
0UQG0ZZRepair vagina, open approach
0UQJ0ZZ-0UQJXZZRepair clitoris [by approach; includes codes 0UQJ0ZZ, 0UQJXZZ]
0UT20ZZ-0UT2FZZResection of bilateral ovaries [by approach; includes codes 0UT20ZZ, 0UT24ZZ, 0UT27ZZ, 0UT28ZZ, 0UT2FZZ]
0UT70ZZ-0UT7FZZResection of bilateral fallopian tubes [by approach; includes codes 0UT70ZZ, 0UT74ZZ, 0UT77ZZ, 0UT78ZZ, 0UT7FZZ]
0UT90ZZ-0UT9FZZResection of uterus [by approach; includes codes 0UT90ZZ, 0UT94ZZ, 0UT97ZZ, 0UT98ZZ, 0UT9FZZ]
0UTC0ZZ-0UTC8ZZResection of cervix [by approach; includes codes 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ]
0UTG0ZZ-0UTG8ZZResection of vagina [by approach; includes codes 0UTG0ZZ, 0UTG4ZZ, 0UTG7ZZ, 0UTG8ZZ]
0UTJ0ZZ-0UTJXZZResection of clitoris [by approach; includes codes 0UTJ0ZZ, 0UTJXZZ]
0UTM0ZZ-0UTMXZZResection of vulva [by approach; includes codes 0UTM0ZZ, 0UTMXZZ]
0VRC0JZReplacement of bilateral testes with synthetic substitute, open approach
0VTC0ZZ-0VTC4ZZResection of bilateral testes [by approach; includes codes 0VTC0ZZ, 0VTC4ZZ]
0VTS0ZZ-0VTSXZZResection of penis [by approach; includes codes 0VTS0ZZ, 0VTS4ZZ, 0VTSXZZ]
0VUS07Z-0VUSX7ZSupplement penis with autologous tissue substitute [by approach, includes codes 0VUS07Z, 0VUS47Z, 0VUSX7Z]
0VUS0JZ-0VUSXJZSupplement penis with synthetic substitute [by approach; includes codes 0VUS0JZ, 0VUS4JZ, 0VUSXJZ]
0VUS0KZ-0VUSXKZSupplement penis with nonautologous tissue substitute [by approach; includes codes 0VUS0KZ, 0VUS4KZ, 0VUSXKZ]
0W4M070Creation of vagina in male perineum with autologous tissue substitute, open approach
0W4M0J0Creation of vagina in male perineum with synthetic substitute, open approach
0W4M0K0Creation of vagina in male perineum with nonautologous tissue substitute, open approach
0W4M0Z0Creation of vagina in male perineum, open approach
0W4N071Creation of penis in female perineum with autologous tissue substitute, open approach
0W4N0J1Creation of penis in female perineum with synthetic substitute, open approach
0W4N0K1Creation of penis in female perineum with nonautologous tissue substitute, open approach

0W4N0Z1

 

Creation of penis in female perineum, open approach

 

ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
F64.1-F64.9Gender identity disorders
  
Discussion/General Information

Gender dysphoria commonly referred to as transsexualism, is a condition wherein an individual's psychological gender is the opposite of his or her anatomic sex.  This results in the persistent feeling of being "trapped in the wrong body".  This diagnosis should not be confused with cross dressing (transvestitism), refusal to accept homosexual orientation, psychotic delusions or personality disorders.  

In May 2013 the American Psychiatric Association published an update to their Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5).  This update included a significant change to the nomenclature of conditions related to gender psychology.  Specifically, the term "Gender Identify Disorder (GID)" was replaced with "Gender Dysphoria".  Additionally, the DSM-5 provided updated diagnostic criteria for gender dysphoria for both children and adults.  The new criteria are as follows:

Gender dysphoria in Children*

  1. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least six of the following (one of which must be Criterion A1):
    1. A strong desire  to be of the other gender or an insistence that one is the other gender (or some alternative gender, different from one's assigned gender)
    2. In boys (assigned gender), a strong preference for cross dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to wearing of typical feminine clothing.
    3. A strong preference for cross-gender roles in make-believe play of fantasy play.
    4. A strong preference for toys, games, or activities stereotypically used or engaged in by the other gender.
    5. A strong preference for playmates of the other gender.
    6. In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough and tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games and activities.
    7. A strong dislike of one's sexual anatomy.
    8. A strong desire for the primary and/or secondary sex characteristics that match one's experienced gender.
  2. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Specify if:
With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 2.55.2 [E25.0] congenital adrenal hyperplasia or 259.0 [E34.50] androgen insensitivity syndrome)
Coding note: Code the disorder of sex development as well as gender dysphoria. 

Gender dysphoria in Adolescents and Adults*

  1. 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:
    1. A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (on 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 (on 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).
  2. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 2.55.2 [E25.0] congenital adrenal hyperplasia or 259.0 [E34.50] androgen insensitivity syndrome)
Coding note: Code the disorder of sex development as well as gender dysphoria.

Specify if:

Post transition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen- namely regular cross-sex treatment or gender reassignment surgery confirming the desired gender (e.g., appendectomy, vaginoplasty in the natal male; mastectomy or phalloplasty in the natal female).

*  From: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.  DSM-5.  American Psychiatric Association. Washington, DC.  May 2013. Page 451-459.

Surgical treatment for gender dysphoria differs depending upon the natal gender of the individual.  For male-to-female individuals, also known as "transwomen," surgery involves removal of the testicles and penis and the creation of pseudo vagina, clitoris, and labia.  For female-to-male individuals, known as "transmen," surgery involves removal of the uterus, ovaries, and vagina, and creation of a neophallus, and scrotum with scrotal prostheses.  At this time, the creation of a neophallus for transmen is a multistage reconstructive procedure.

The medical necessity criteria above are based upon the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, Seventh Version, published by the World Professional Association for Transgender Health (WPATH) (2011).  This document is widely accepted as the definitive document in the area of gender dysphoria treatment, and it has cited in numerous articles by other respected authors and organizations.  The WPATH criteria have been adopted in several countries as the standard of care for the treatment of gender dysphoria, including hormone therapy and gender reassignment surgery.

The criteria in the SOC are supported by evidence-based peer-reviewed journal publications.  Several studies have shown that extensive long-term trials of hormonal therapy and real-life experience living as the other gender, as well as social support and acceptance by peer and family groups, greatly improve psychological outcomes in individuals undergoing gender reassignment surgery (Eldh, 1997; Landen, 1998).  A study reported by Monstrey and colleagues (2001) described the importance of close cooperation between the many medical and behavioral specialties required for proper treatment of individuals with gender dysphoria who wish to undergo gender reassignment surgery.  Similar findings were reported earlier by Schlatterer et al. in 1996.  One study of 188 subjects undergoing gender reassignment surgery found that dissatisfaction with surgery was highly associated with sexual preference, psychological co-morbidity, and poor pre-operative body image and satisfaction (Smith, 2005).                                                                                                

Gender reassignment surgery presents significant medical and psychological risks, and the results are irreversible.  A step-wise approach to therapy for gender dysphoria, including accurate diagnosis and long-term treatment by a multidisciplinary team including behavioral, medical and surgical specialists, has been shown to provide the best results.  As with any treatment involving psychiatric disorders, a thorough behavioral analysis by a qualified practitioner is needed.  Once a diagnosis of gender dysphoria is established, treatment with hormone therapy and establishment of real-life transgender experience may be warranted.  Gender reassignment surgery should be considered only after such trials have been undertaken, evaluated and confirmed.  Hormone therapy, when indicated, should be administered under ongoing medical supervision and is important in beginning the gender transition process by altering body hair, breast size, skin appearance and texture, body fat distribution, and the size and function of sex organs.  Additionally, real-life experience living as the desired gender is important to validate the individual's desire and ability to incorporate into their desired gender role within their social network and daily environment.  This generally involves gender-specific appearance (garments, hairstyle, etc.), involvement in various activities in the desired gender role including work or academic settings, legal acquisition of a gender appropriate first name, and acknowledgement by others of their new gender role.  With regard real-life experience, to the 2011 WPATH document specifically states:

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. As noted in section VII, the social aspects of changing one's gender role are usually challenging – often more so than the physical aspects. Changing gender role can have profound personal and social consequences, and the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role. Support from a qualified mental health professional and from peers can be invaluable in ensuring a successful gender role adaptation (Bockting, 2008).

The duration of 12 months allows for a range of different life experiences and events that may occur throughout the year (e.g., family events, holidays, vacations, season-specific work or school experiences). During this time, patients should present consistently, on a day-to-day basis and across all settings of life, in their desired gender role. This includes coming out to partners, family, friends, and community members (e.g., at school, work, other settings).

Health professionals should clearly document a patient's experience in the gender role in the medical chart, including the start date of living full time for those who are preparing for genital surgery. In some situations, if needed, health professionals may request verification that this criterion has been fulfilled: They may communicate with individuals who have related to the patient in an identity-congruent gender role, or request documentation of a legal name and/or gender marker change, if applicable.

Once these treatment steps have been established, and have been stable for at least 12 months, an individual may be considered for gender reassignment surgery.

For both transmen and transwomen, additional surgeries have been proposed to improve the gender appropriate appearance of the individual.  Procedures such as breast augmentation, liposuction, Adam's apple reduction, rhinoplasty, facial reconstruction, and others have no medically necessary role in gender identification and are considered cosmetic in nature.

References

Peer Reviewed Publications:

  1. 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.
  2. Cohen-Kettenis PT, Gooren LJ. Transsexualism: a review of etiology, diagnosis and treatment. J Psychosom Res. 1999; 46(4):315-333.
  3. 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.
  4. Hepp U, Kraemer B, Schnyder U, et al.  Psychiatric comorbidity in gender identity disorder. J Psychosom Res. 2005; 58(3):259-261.  
  5. Landen M, Walinder J, Hambert G, Lundstrom B. Factors predictive of regret in sex reassignment. Acta Psychiatr Scand. 1998; 7(4):284-289. 
  6. Mate-Kole C, Freschi M, Robin A.  A controlled study of psychological and social change after surgical gender reassignment in selected male transsexuals. Br J Psychiatry. 1990; 157:261-264. 
  7. Midence K, Hargreaves I.  Psychosocial adjustment in male-to-female transsexuals: an overview of the research evidence. J Psychol. 1997; 131(6):602-614.
  8. Monstrey S, Hoebeke P, Dhont M, et al.  Surgical therapy in transsexual patients: a multi-disciplinary approach. Acta Chir Belg. 2001; 101(5):200-209.
  9. Parkes G, Hall I.  Gender dysphoria and cross-dressing in people with intellectual disability: a literature review. Ment Retard. 2006; 44(4):260-271.
  10. Schlatterer K, von Werder K, Stalla GK. Multistep treatment concept of transsexual patients. Exp Clin Endocrinol Diabetes. 1996; 104(6):413-419.
  11. Selvaggi G, Ceulemans P, De Cuypere G, et al.  Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plast Reconstr Surg. 2005; 116(6):135e-145e.
  12. Smith YL, Van Goozen SH, Kuiper AJ, Cohen-Kettenis PT.  Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals. Psychol Med. 2005; 35(1):89-99.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 2013. Washington, DC. Pages 451-459.
  2. Centers for Medicare and Medicaid Services. National Coverage Determination: Transsexual Surgery. NCD #140.3. Effective date not available. Available at: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd.  Accessed on May 29, 2013.
  3. Day P. Trans-gender reassignment surgery. New Zealand health technology assessment (NZHTA). The clearing house for health outcomes and Health technology assessment.  February 2002; Volume 1 Number 1 Available at: http://nzhta.chmeds.ac.nz/publications/trans_gender.pdf.  Accessed on May 29, 2013.
  4. World Professional Association for Transgender Health (WPATH). Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th version. 2011.  Available at: http://www.wpath.org/documents/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf.  Accessed on May 29, 2013.
  5. World Professional Association for Transgender Health (WPATH) (formerly The Harry Benjamin International Gender Dysphoria Association).  Standards of Care for Gender Identity Disorders. 6th version. 2001 Feb. Available at: http://wpath.org/Documents2/socv6.pdf.  Accessed on May 29, 2013.
Index

Sex Change
Sex Reassignment

History
StatusDateAction
Revised08/08/2013Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised07/26/2013Behavioral Health Subcommittee review. Revised document text to align with new DSM-5 terminology and diagnostic criteria. Updated Discussion and Reference sections.
Revised08/09/2012MPTAC review.
Revised08/03/2012Behavioral Health Subcommittee review. Created separate criteria sets for gonad and reproductive organ procedures and for external genital procedures in alignment with the WPATH SOC7. Deleted the criteria requiring 12 months of continuous living in desired gender role from the reproductive organ procedures criteria set. Deleted criteria requiring "Demonstrable knowledge of the required length of hospitalizations, likely complications, and post surgical rehabilitation requirements of various surgical approaches".  Deleted "not due to chromosomal abnormality" from medically necessary criteria. Updated Coding, Discussion and Reference sections.
Revised02/16/2012MPTAC review.
Revised02/10/2012Behavioral Health Subcommittee review. Significantly revised the medically necessary to align with new 2011 WPATH Standards of Care document.  Updated Rationale and Reference sections.
Reviewed05/19/2011MPTAC review. No change to position statement. 
Reviewed05/13/2010MPTAC review. No change to position statement.  Updated Reference section.
Reviewed11/19/2009MPTAC review. No change to indications.  Updated Coding section with 01/01/2010 CPT changes.
Reviewed11/20/2008MPTAC review. No change to indications.  Updated coding section
Reviewed11/29/2007MPTAC review. No change to policy position statement.  Updated Coding section with 01/01/2008 CPT changes.
New12/07/2006Medical Policy & Technology Assessment Committee (MPTAC) initial guideline development.