02/05/2007

12/07/2006

Gender reassignment surgery is one treatment option for extreme cases of Gender Identity Disorder (GID), 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 GID 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 modalities working in conjunction with each other and the patient 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 patient.

Please refer to the following documents for additional information:

• ANC.00007 Cosmetic and Reconstructive Services: Skin Related
• ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
• ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
• SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery
• CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift

Medically Necessary:

Gender reassignment surgery* is considered medically necessary when the all following criteria are met:

1. The patient is at least 18 years of age; and
2. The patient has been diagnosed with the Gender Identity Disorder (GID) of transsexualism, including 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 or a chromosomal abnormality; and
4. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and
3. For those patients without a medical contraindication, the patient 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
4. The patient has completed a minimum of 12 months of successful continuous full time real-life experience with no returning to their original gender, including one or more of the following:
1. Maintain part- or full-time employment; or
2. Function as a student in an academic setting; or
3. Function in a community-based volunteer activity; and
5. Acquire a legal gender-identity-appropriate name change; and
6. The patient has provided documentation to the treating therapist that persons other than the treating therapist know that the patient functions in the desired gender role; and
7. Regular participation in psychotherapy throughout the real-life experience when recommended by a treating medical or behavioral health practitioner; and
8. Demonstrable knowledge of the required length of hospitalizations, likely complications, and post surgical rehabilitation requirements of various surgical approaches; and
9. Demonstrable progress in consolidating one’s gender identity, including demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, suicidality, for instance); and
10. A letter** from the patient’s physician or mental health provider, who has treated the patient for a minimum of 18 months, documenting the following:
1. The patient's general identifying characteristics; and
2. The initial and evolving gender, sexual, and other psychiatric diagnoses; and
3. The duration of their professional relationship including the type of psychotherapy or evaluation that the patient underwent; and
4. The eligibility criteria that have been met and the mental health professional’s rationale for surgery; and
5. The degree to which the patient has followed the eligibility criteria to date and the likelihood of future compliance; and
6. Whether the author of the report is part of a gender team; and
11. A letter** from a second physician or mental health provider familiar with the patient’s treatment and the psychological aspects of Gender Identity Disorders, corroborating the information provided in the first letter (see #10 above); and
12. When one of the signatories on the letters indicated above is not the treating surgeon, a letter from the surgeon confirming that that they have personally communicated with the treating therapist and or physician, as well as the patient, and confirming that the patient meets the above criteria, understands the ramifications and possible complications of surgery, and that the surgeon feels that the patient is likely to benefit from surgery.

* Sex reassignment surgery may include any of the following procedures:

Male-to-Female Procedures

• Orchiectomy
• Penectomy
• Vaginoplasty
• Clitoroplasty
• Labiaplasty

Female-to-Male Procedures

• Hysterectomy
• Salpingo-oophorectomy
• Vaginectomy
• Metoidioplasty
• Scrotoplasty
• Urethroplasty
• Placement of testicular prostheses
• Phalloplasty

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 a patient 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

The following codes for treatments and procedures applicable to this guideline 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.

CPT

55970	Intersex surgery; male to female
55980	Intersex surgery; female to male
	Also individual procedures if billed separately, including but not limited to
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
55180	Scrotoplasty; complicated
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
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 grams or less; with removal of tube(s) and/or ovary(s)
58554	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s)

ICD-9 Procedure

62.41	Removal of both testes at same operative episode
62.7	Insertion of testicular prosthesis
64.3	Amputation of penis
64.43	Construction of penis
64.5	Operations for sex transformation, not elsewhere classified
65.61	Other removal of both ovaries and tubes at same operative session
65.63	Laparoscopic removal of both ovaries and tubes at the same operative episode
68.4	Total abdominal hysterectomy
68.51	Laparoscopically assisted vaginal hysterectomy (LAVH)
68.59	Other vaginal hysterectomy
70.4	Obliteration and total excision of vagina
70.61	Vaginal construction
71.4	Operations on clitoris
71.62	Bilateral vulvectomy

ICD-9 Diagnosis

302.6	Gender identity disorder in children or NOS
302.85	Gender identity disorder in adolescents or adults

Gender Identity Disorder, 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.

Surgical treatment differs depending upon the original physical gender of the patient. For male-to-female patients, 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 patients, 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 guideline criteria above are based upon: 1) the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR, 2000) criteria for the diagnosis of Gender Identity Disorder (GID); and 2) the Standards of Care (SOC) for Gender Identity Disorders (GID), Sixth Version, published by the Harry Benjamin International Gender Dysphoria Association (2001). Both of these references are widely accepted as definitive documents in the area of GID treatment and cited in numerous articles by respected authors. The SOC criteria have been adopted in several countries as the standard of care for the treatment of GID, 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, as well as social support and acceptance by peer and family groups, greatly improve psychological outcomes in patients 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 patients with GID who wish to undergo gender reassignment surgery. Similar findings were reported earlier by Schlatterer et al. in 1996. One study of 188 patients 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).

Undertaking gender reassignment surgery is obviously a very serious decision. The procedures present significant medical and psychological risks, and results are irreversible. A step-wise approach to therapy for GID, 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 GID 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 should be administered under on-going 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 is important to validate the patient’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.

Once these treatment steps have been established and stable for at least 12 months, a patient 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 patient. 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.

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). 2000. Washington, DC. Pages 576-582.
2. Becker S, Bosinski H, Clement U, et al. German Standards for the Treatment and Diagnostic Assessment of Transsexuals. Issued by the German Society for Sexual Research, the Academy for Sexual Medicine and the Society for Sexual Sciences. Int J Transgender 1998; 2(4). Available at: http://www.symposion.com/ijt/ijtc0603.htm. Accessed on November 6, 2006.
3. 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.
4. Cohen-Kettenis PT, Gooren LJ. Transsexualism: a review of etiology, diagnosis and treatment. J Psychosom Res. 1999; 46(4):315-333.
5. Centers for Medicare and Medicaid Services. National Coverage Determination: Transsexual. NCD #140.3. Effective date not available. Available at: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on November 6, 2006.
6. 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 November 6, 2006.
7. 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.
8. Hayes, Inc. Hayes Medical Technology Directory. Sex reassignment surgery and associated therapies for the treatment of gender identity disorder. Lansdale, PA: Hayes, Inc.; December 2004. Search updated December 20, 2005.
9. Hepp U, Kraemer B, Schnyder U, Miller N, Delsignore A. Psychiatric comorbidity in gender identity disorder. J Psychosom Res. 2005; 58(3):259-261.
10. Landen M, Walinder J, Hambert G, Lundstrom B. Factors predictive of regret in sex reassignment. Acta Psychiatr Scand. 1998; 7(4):284-9.
11. 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.
12. Midence K, Hargreaves I. Psychosocial adjustment in male-to-female transsexuals: an overview of the research evidence. J Psychol. 1997; 131(6):602-614.
13. 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.
14. Parkes G, Hall I. Gender dysphoria and cross-dressing in people with intellectual disability: a literature review. Ment Retard. 2006; 44(4):260-71.
15. Schlatterer K, von Werder K, Stalla GK. Multistep treatment concept of transsexual patients. Exp Clin Endocrinol Diabetes. 1996; 104(6):413-419.
16. 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.
17. 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.
18. The Harry Benjamin International Gender Dysphoria Association. Standards of Care for Gender Identity Disorders. 6th version. 2001 Feb. Available at: http://www.hbigda.org/Documents2/socv6.pdf. Accessed on: November 6, 2006.

Sex Change
Sex Reassignment

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.

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