Clinical UM Guideline
|Subject:||Sex Reassignment Surgery|
|Guideline #:||CG-SURG-27||Current Effective Date:||08/18/2016|
|Status:||Revised||Last Review Date:||08/04/2016|
This document addresses sex reassignment surgery (also known as gender reassignment surgery and gender confirmation surgery), which 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. Sex 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 sex 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.
Note: Please refer to the following documents for additional information:
For individuals undergoing sex reassignment surgery, consisting of any combination of the following; hysterectomy, salpingo-oophorectomy, ovariectomy, or orchiectomy, it is considered medically necessary when all of the following criteria are met:
For individuals undergoing sex reassignment surgery, consisting of any combination of the following, metoidioplasty, phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, or placement of testicular prostheses, it is considered medically necessary when all of the following criteria are met:
*At least one of the professionals submitting a letter must have a doctoral degree (for example, Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D) or a master's level degree in a clinical behavioral science field (for example, M.S.W., L.C.S.W., Nurse Practitioner [N.P.], Advanced Practice Nurse [A.P.R.N.], Licensed Professional Councilor [L.P.C.], and Marriage and Family Therapist [M.F.T.]) 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 specifications set forth above.
** 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
For individuals undergoing sex reassignment surgery, bilateral mastectomy is considered medically necessary when ALL of the following criteria have been met:
The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary.
Not Medically Necessary:
Sex reassignment surgery is considered not medically necessary when one or more of the criteria above have not been met.
The following procedures are considered cosmetic when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo sex reassignment surgery, including, but not limited to, the following:
Note: Please refer to Anthem documents ANC.00007, ANC.00008 and ANC.00009 for more information regarding the use of these and other procedures for individuals with gender dysphoria that are not planning sex reassignment surgery.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. 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.
|55970||Intersex surgery; male to female|
|55980||Intersex surgery; female to male|
|Also combinations of individual procedures billed separately, including but not limited to|
|17380||Electrolysis epilation, each 30 minutes|
|17999||Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as permanent hair removal by laster]|
|19303||Mastectomy, simple, complete|
|19325||Mammaplasty, augmentation; with prosthetic implant|
|54125||Amputation of penis; complete|
|54520||Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach|
|54660||Insertion of testicular prosthesis|
|54690||Laparoscopy, surgical; orchiectomy|
|56625||Vulvectomy, simple; complete|
|56800||Plastic repair of introitus|
|56805||Clitoroplasty for intersex state|
|57110||Vaginectomy, complete removal of vaginal wall;|
|57291||Construction of artificial vagina; without graft|
|57292||Construction of artificial vagina; with graft|
|57295||Revision (including removal) of prosthetic vaginal graft; vaginal approach|
|57296||Revision (including removal) of prosthetic vaginal graft; open abdominal approach|
|57426||Revision (including removal) of prosthetic vaginal graft, laparoscopic approach|
|58150||Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);|
|58552||Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)|
|58554||Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)|
|58570||Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less;|
|58571||Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)|
|58572||Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;|
|58573||Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)|
|0HBV0ZZ-0HBVXZZ||Excision of breast, bilateral [by approach; includes codes 0HBV0ZZ, 0HBV3ZZ, 0HBV7ZZ, 0HBV8ZZ, 0HBVXZZ]|
|0HDSXZZ||Extraction of hair, external approach|
|0UQG0ZZ||Repair vagina, open approach|
|0UQJ0ZZ-0UQJXZZ||Repair clitoris [by approach; includes codes 0UQJ0ZZ, 0UQJXZZ]|
|0UT20ZZ-0UT2FZZ||Resection of bilateral ovaries [by approach; includes codes 0UT20ZZ, 0UT24ZZ, 0UT27ZZ, 0UT28ZZ, 0UT2FZZ]|
|0UT70ZZ-0UT7FZZ||Resection of bilateral fallopian tubes [by approach; includes codes 0UT70ZZ, 0UT74ZZ, 0UT77ZZ, 0UT78ZZ, 0UT7FZZ]|
|0UT90ZZ-0UT9FZZ||Resection of uterus [by approach; includes codes 0UT90ZZ, 0UT94ZZ, 0UT97ZZ, 0UT98ZZ, 0UT9FZZ]|
|0UTC0ZZ-0UTC8ZZ||Resection of cervix [by approach; includes codes 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ]|
|0UTG0ZZ-0UTG8ZZ||Resection of vagina [by approach; includes codes 0UTG0ZZ, 0UTG4ZZ, 0UTG7ZZ, 0UTG8ZZ]|
|0UTJ0ZZ-0UTJXZZ||Resection of clitoris [by approach; includes codes 0UTJ0ZZ, 0UTJXZZ]|
|0UTM0ZZ-0UTMXZZ||Resection of vulva [by approach; includes codes 0UTM0ZZ, 0UTMXZZ]|
|0VRC0JZ||Replacement of bilateral testes with synthetic substitute, open approach|
|0VTC0ZZ-0VTC4ZZ||Resection of bilateral testes [by approach; includes codes 0VTC0ZZ, 0VTC4ZZ]|
|0VTS0ZZ-0VTSXZZ||Resection of penis [by approach; includes codes 0VTS0ZZ, 0VTS4ZZ, 0VTSXZZ]|
|0VUS07Z-0VUSX7Z||Supplement penis with autologous tissue substitute [by approach, includes codes 0VUS07Z, 0VUS47Z, 0VUSX7Z]|
|0VUS0JZ-0VUSXJZ||Supplement penis with synthetic substitute [by approach; includes codes 0VUS0JZ, 0VUS4JZ, 0VUSXJZ]|
|0VUS0KZ-0VUSXKZ||Supplement penis with nonautologous tissue substitute [by approach; includes codes 0VUS0KZ, 0VUS4KZ, 0VUSXKZ]|
|0W4M070||Creation of vagina in male perineum with autologous tissue substitute, open approach|
|0W4M0J0||Creation of vagina in male perineum with synthetic substitute, open approach|
|0W4M0K0||Creation of vagina in male perineum with nonautologous tissue substitute, open approach|
|0W4M0Z0||Creation of vagina in male perineum, open approach|
|0W4N071||Creation of penis in female perineum with autologous tissue substitute, open approach|
|0W4N0J1||Creation of penis in female perineum with synthetic substitute, open approach|
|0W4N0K1||Creation of penis in female perineum with nonautologous tissue substitute, open approach|
|0W4N0Z1||Creation of penis in female perineum, open approach|
|F64.0-F64.9||Gender identity disorders [Note: ICD-10-CM code F64.0 is effective for services on or after 10/01/2016]|
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 Identity 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*
Gender dysphoria in Adolescents and Adults*
*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) (2013). 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 sex 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 sex 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 sex reassignment surgery. Similar findings were reported earlier by Schlatterer et al. in 1996. One study of 188 subjects undergoing sex 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).
Sex reassignment surgery presents significant medical and psychological risks, and the results are difficult to reverse (Djordjevic, 2016). Some procedures are irreversible, such as removal of gonad tissue. 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. Sex 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. Hormone therapy is consistent with the development of secondary sexual characteristics vital to gender transition, and should be administered unless contraindicated. 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 2013 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 sex reassignment surgery.
In many instances, the creation of a neovagina or a urethra for a neopenis requires an autologous skin graft from the forearm or thigh. Such skin may be excessively hairy, which will impair the function of the newly constructed organ if not permanently removed. Pre-operative permanent hair removal treatments to these areas may be warranted to prevent post-operative complications.
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.
The clinical evidence addressing the satisfaction and quality of life following sex reassignment surgery is limited, and the reported findings are mixed (Cardoso da Silva, 2016; Castellano, 2015). It is important that proper and thorough pre-operative work-up and preparation be conducted in individuals considering such life-altering procedures.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Revised||08/04/2016||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|Revised||07/29/2016||Behavioral Health Subcommittee review. Updated formatting in the Clinical Indications section. Added bilateral mastectomy to MN section with criteria. Updated Reference sections. Updated Coding section to include 10/01/2016 ICD-10-CM changes.|
|Revised||05/05/2016||MPTAC review. Revised title from "Gender Reassignment Surgery" to "Sex Reassignment Surgery". Updated Coding, Rationale and Discussion section.|
|Revised||01/29/2016||Behavioral Health Subcommittee review. Added new medically necessary statement addressing the use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure. Added additional procedures to Cosmetic statement. Updated Coding and Rationale sections. Removed ICD-9 codes from Coding section.|
|Revised||07/31/2015||Behavioral Health Subcommittee review. Revised text regarding educational and professional qualifications required for individuals submitting referral letters to include master's-level practitioners. Added text to referral letter criteria, requiring that letters need to be no more than 12 months old at time of request. Revised criteria regarding hormone therapy requirements. Replaced the word 'surgeries' with 'procedures' in Cosmetic statement. Added note to Cosmetic section.|
|Reviewed||08/08/2014||Behavioral Health Subcommittee review.|
|Revised||07/26/2013||Behavioral Health Subcommittee review. Revised document text to align with new DSM-5 terminology and diagnostic criteria. Updated Discussion and Reference sections.|
|Revised||08/03/2012||Behavioral 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.|
|Revised||02/10/2012||Behavioral Health Subcommittee review. Significantly revised the medically necessary to align with new 2012 WPATH Standards of Care document. Updated Rationale and Reference sections.|
|Reviewed||05/13/2010||MPTAC review. Updated Reference section.|
|Reviewed||11/19/2009||MPTAC review. Updated Coding section with 01/01/2010 CPT changes.|
|Reviewed||11/20/2008||MPTAC review. Updated coding section|
|Reviewed||11/29/2007||MPTAC review. Updated Coding section with 01/01/2008 CPT changes.|
|New||12/07/2006||Medical Policy & Technology Assessment Committee (MPTAC) initial guideline development.|