Archived Policies - Surgery
Gender Assignment Surgery (GAS) and Gender Reassignment Surgery (GRS) with Related Services
Gender assignment surgery (GAS) for patients with ambiguous genitalia is considered reconstructive surgery and may be considered medically necessary.
Gender reassignment surgery (GRS), also known as transsexual surgery, or sex reassignment surgery, is considered not medically necessary.
To Determine Individual Eligibility Coverage
for Gender Reassignment Surgery and Related Services
WHEN Contract or Group Certificate Allows Medical Necessity:
If the not medically necessary or cosmetic exclusion is not applicable to GRS, utilize the following criteria for benefit coverage of services included in GRS services.
The member’s contract or certificate of coverage must allow specifically for GRS AND the member must meet ALL selection criteria.
Therefore CAREFULLY REVIEW the member’s benefit plan, summary plan description or contract for GRS provisions. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
For an individual whose benefit certificate covers GRS, the individual being considered for surgery must meet ALL the following criteria. The individual must have:
NOTE regarding mental health services: If the first referral is from the individual’s psychotherapist, the second referral should be from a clinician who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both, for example if both are practicing within the same clinic or program, may be sent. Psychotherapy is not required for GRS except when the mental health professional's initial assessment recommends psychotherapy that specifies the goals of treatment, estimates its frequency and duration throughout the real life experience.
To Determine Medical Necessity
for Gender Reassignment Surgery and Related Services
WHEN Contract or Group Certificate Individual Eligibility Has Been Established:
The following section addresses specific procedures and services that may be performed.
NOTE: Some benefit plans may specify coverage for individual components of GRS. Therefore CAREFULLY REVIEW the member’s benefit plan, summary plan description or contract for GRS provisions. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Male to Female (MtF) procedures that may be considered as part of the GRS when the benefit coverage allows services for GRS for an individual who has met the above selection criteria include:
Female to Male (FtM) procedures that may be considered as part of the GRS when the benefit coverage allows services for GRS for an individual who has met the above selection criteria include:
The following procedures or services are considered cosmetic or not medically necessary when used to improve the gender specific appearance of an individual who is planning to undergo or has undergone GRS, including but not limited to:
Additional gender specific preventive medicine services that may be covered for GRS individuals who are planning to undergo or have undergone GRS:
NOTE: Continuous hormone replacement therapy services may be included in the specific coverage components allowed by some benefit plans. Therefore CAREFULLY REVIEW the member’s benefit plan, summary plan description or contract for GRS provisions. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern. Continuous hormone replacement therapy may include the following services:
Laboratory testing may be done to monitor continuous hormone therapy for GRS individuals who are planning to undergo or have undergone GRS.
NOTE: Psychotherapy services may be included in the specific coverage components allowed by some benefit plans. Therefore CAREFULLY REVIEW the member’s benefit plan, summary plan description or contract for GRS provisions. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, sperm, and testicular tissue from individuals who are planning to undergo or have undergone GRS, despite whether or not the individual has reproduced in the past, is considered not medically necessary.
Gender assignment surgery (GAS), also known as genitoplasty, is the genital reconstruction as a result of ambiguous genitalia in those individuals for whom it was difficult to classify them as a male or female infant. The extent of the ambiguity varies. In very rare instances, the physical appearance may be fully developed as the opposite of the genetic sex (e.g., a genetic male may have developed the appearance of a normal female). (1) To the lay person the determination of an infant’s sex can easily be identified as male or female, by virtue of outward genital anatomy, secondary sexual characteristics and behavior within their relevant cultural context. Arriving at a satisfactory scientific definition is more difficult as gender reflects the outcome of complex interactions occurring from the time of conception and extending throughout pre- and postnatal life. (2)
Intersex anomalies associated with ambiguous genitalia may result from major chromosomal abnormalities or from specific gene mutations as in congenital adrenal hyperplasia (CAH). (2) Typically, the ambiguous genitalia in genetic females (babies with two X chromosomes) include an enlarged clitoris that has the appearance of a small penis. The urethral opening can be anywhere along, above, or below the surface of the clitoris. The labia may be fused, resembling a scrotum. The infant may be thought to be a male with undescended testicles. Sometimes a lump of tissue is felt within the fused labia, further making it look like a scrotum with testicles. (3, 4)
In a genetic male (babies with one X and one Y chromosome), the ambiguous genitalia typically include a small penis (less than 2-3 centimeters or 0.8-1.2 inches) that may appear to be an enlarged clitoris (the clitoris of a newborn female is normally somewhat enlarged at birth). The urethral opening may be anywhere along, above, or below the penis; it can be placed as low as on the peritoneum, further making the infant appear to be female. There may be a small scrotum with any degree of separation, resembling labia. Undescended testicles commonly accompany ambiguous genitalia. (3, 4)
Disorders which include ambiguous genitalia, which are usually not life threatening, have serious and potentially lifelong consequences for the affected child and, depending on the underlying cause, are likely to entail surgery in childhood and in later life, for example endocrine replacement therapy in conjunction with steroid replacement for those with CAH. (1) Making a correct determination of gender is both important for treatment purposes, as well as the emotional well-being of the child. Some children born with ambiguous genitalia may have normal internal reproductive organs that allow them to live normal lives. However, others may experience health issues from an underlying cause of the disorder. A list of the most common causes is listed below:
Gender reassignment surgery (GRS), also known as sex reassignment surgery; genital reconstruction surgery; sex affirmation surgery; sex realignment surgery; intersex surgery, or sex-change operation, is a term used for the culmination of a series of surgical procedures and treatments by which a person’s physical appearance and function(s) of the existing sexual characteristics are altered or even permanently transformed/changed to resemble or conform to that of the opposite sex. Other terms are used to describe these procedures, such as sex reconstruction surgery; gender confirmation surgery; feminizing genitoplasty or penectomy, orchidectomy and vaginoplasty are used for trans-women, with masculinizing genitoplasty or phalloplasty often used for trans-men. These procedures and services make up the treatment of individuals diagnosed with gender identity disorder or gender dysphoria in transsexual or transgender people. GRS may be performed on intersex people, often in infancy, without their consent. (1, 2, 5, 6, 7)
GRS has been clarified by the World Professional Association for Transgender Health (WPATH) (1), formerly known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA) (8), an international, multispecialty, professional association whose mission is to promote evidence-based care, education, research, advocacy, public policy, and respect for transgender health. In May 2010, WPATH urged the de-psychopathologization of gender nonconformity worldwide, by stating, “The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common culturally-diverse human phenomenon [that] should not be judged as inherently pathological or negative.” WPATH clarified the related procedures and services when an individual is considering surgical transformation from male-to-female (MtF) or female-to-male (FtM), as well as how the treatment differs for gender identity disorder, gender dysphoria, and transsexualism. (1)
Terminology in Relationship to Transgender Health
Terminology in the area of health care for transsexual, transgender, and gender nonconforming individuals is rapidly evolving; new terms are being introduced, and the definitions of existing terms are changing. Thus, there is often misunderstanding, debate, or disagreement about language in this field. Terms that may be unfamiliar or that have specific meanings in the “Standards of Care” (SOC) are defined below for the purpose of this document only. Others may adopt these definitions, but WPATH acknowledges that these terms may be defined differently in different cultures, communities, and contexts. (1)
Gender Assignment Surgery (GAS)
The ability to diagnose infants born with intersex conditions has advanced rapidly in recent years. In most cases today, clinicians can promptly make an accurate diagnosis and counsel parents on therapeutic options. However, the paradigm of early gender assignment has been challenged by the results of clinical and basic science research, which show that gender identity development likely begins in utero. While the techniques of surgical genital reconstruction have been mastered, the understanding of the psychological and social implications of gender assignment is poor. (1, 2, 3)
Treatment of ambiguous genitalia is controversial. No one debates the need to treat underlying physiologic problems such as those associated with congenital adrenal hyperplasia (CAH) or tumors in the gonads. However treatment for ambiguous genitalia depends on the type of disorder, but will usually include corrective surgery to remove or create reproductive organs appropriate for the gender of the child. Treatment may also include hormone replacement therapy (HRT). Controversy revolves around issues of gender reassignment by the physician and family which may not correlate with gender preference by the patient in adulthood. (1, 2, 3, 4)
Reilly and Woodhouse interviewed and examined 20 patients with the primary diagnosis of micropenis in infancy” and concluded, “[A] small penis does not preclude a normal male role and a micropenis or microphallus alone should not dictate a female gender reassignment in infancy.” More particularly, these doctors found that when parents “were well counseled about the diagnosis they reflected an attitude of concern but not anxiety about the problem, and they did not convey anxiety to their children. They were honest and explained problems to the child and encouraged normality in behavior. We believe that this is the attitude that allows these children to approach their peers with confidence. (2, 3, 4, 9)
From a medico-legal standpoint, the best approach to managing these cases is to provide parents with as much information as possible so that they can make informed decisions. Adequate counseling and support for parents is vital. The ideal management method is a team approach including neonatologists, geneticists, endocrinologists, surgeons, counselors, and ethicists. (2, 3, 10)
Gender Reassignment Surgery (GRS)
Gender reassignment surgery is controversial among the available literature and few long term studies can be located. These controversial differences are most apparent due to the far reaching and irreversible results of hormonal and/or surgical transformation and the high rate of serious complications of these procedures. (6)
Postoperative complications include infection, hemorrhage, urethral urinary incontinence, rectal fistula, vaginal stenosis, and erectile tissue around the urethral meatus. Serious postoperative incidents include request for reversal, hospitalization and suicide. The incidence of the number of events attributed to postoperative complications cannot be ascertained with confidence due to variability between the studies, and the high rates of losses to follow up. (2, 11) Case series give some indication on the frequency of these events, although there is great variation in the figures presented, and suicide rates range from 0% to 18%. This data should be interpreted with caution, as figures are derived from small studies in which there are no control groups, incomplete follow up and the possibility of bias in reporting. (12, 13, 14)
Thrombotic risk of estrogen therapy should be considered when estimating potential harms of gender reassignment interventions. (15)
New problems may emerge following reassignment surgery. Some individuals may need to come to terms with painful loss including jobs, families, partners, children and friends. Many are forced to move away from their familiar environments despite being confident in their new gender roles. Many individuals have difficulty with social adaptation and acceptance by other members of society. (17, 18)
The evidence to support gender reassignment surgery is limited in that most studies are non-controlled and have not collected data prospectively. In addition, they are hampered by losses to follow up and a lack of validated assessment measures. It has been noted that a number of transsexual people experience a successful outcome in terms of subjective well-being, cosmesis and sexual function. The magnitude of benefit and harm cannot be estimated accurately using current evidence. (16, 18)
A MedLine search of peer reviewed literature through October 2012 identified one cohort study in Sweden of 324 sex-reassigned persons (191 male-to-female [MtF] and 133 female-to-male [FtM]). (19) The objective of this long-term follow-up study was to estimate mortality, morbidity, and criminal rate after GRS from 1973-2003. Dhejne et al. reported the overall mortality for sex-reassigned person was higher during the follow-up than the random controls of the matched by birth year and birth sex. The deaths primarily were from suicide. The sex-reassigned persons had an increased risk of suicide attempts and psychiatric inpatient care. There was a higher risk of criminal convictions in the FtM compared to controls, but not in the MtF group. The results suggest that GRS may alleviate the gender dysphoria, but may not suffice as treatment for individuals’ transsexualism. GRS remains controversial. (19)
The lack of well-controlled, long term studies of the safety and effectiveness of the GRS procedures and related services to complete the transformation from one sex to another, along with the serious complications that may occur, would not change the coverage position of this medical policy. GRS remains as not medically necessary.
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
The following codes may be applicable to this Medical policy and may not be all inclusive.
11950, 11951, 11954, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 17380, 19301, 19303, 19304, 19316, 19318, 19324, 19325, 19340, 19342, 19350, 21120, 21121, 21122, 21123, 21125, 21127, 30400, 30410, 30420, 30430, 30435, 30450, 53430, 54125, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54520, 54660, 54690, 55175, 55180, 55970, 55980, 56625, 56800, 56805, 56810, 57106, 57107, 57110, 57111, 57291, 57292, 57295, 57296, 57335, 57426, 58150, 58180, 58260, 58262, 58275, 58280, 58285, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58661, 58720, 90845, 90846, 90847, 90849, 90853, [Deleted 1/2013: 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90857]
ICD-9 Diagnosis Codes
302.50, 302.51, 302.52, 302.53, 302.6, 302.85, 752.7, 752.89, 758.81
ICD-9 Procedure Codes
62.41, 62.7, 64.3, 64.43, 64.5, 64.97, 65.61, 65.63, 68.41-68.49, 68.51, 68.59, 70.4, 70.61, 71., 71.62
ICD-10 Diagnosis Codes
Refer to the ICD-10-CM Manual
ICD-10 Procedure Codes
OVT, OVR, OW4, OVU
The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.
The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.
A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov.
3/15/2013 Document updated with literature review. Coverage unchanged. The following was added: Gender reassignment surgery and related services, for those members with a contract or a certificate of coverage that would allow for GRS, when specific criteria are met. Title changed from Gender Reassignment Surgery to Gender Assignment Surgery (GAS) and Gender Reassignment Surgery (GRS) with Related Services. Policy removed from no further review status.
4/1/2008 Policy reviewed without literature review; new review date only. This policy is no longer scheduled for routine literature review and update.
5/1/2006 New medical document
|Title:||Effective Date:||End Date:|
|Gender Assignment Surgery and Gender Reassignment Surgery with Related Services||03-15-2018||04-30-2019|
|Gender Assignment Surgery and Gender Reassignment Surgery with Related Services||10-01-2016||03-14-2018|
|Gender Assignment Surgery and Gender Reassignment Surgery with Related Services||11-06-2015||09-30-2016|
|Gender Assignment Surgery (GAS) and Gender Reassignment Surgery (GRS) with Related Services||07-01-2014||11-05-2015|
|Gender Assignment Surgery (GAS) and Gender Reassignment Surgery (GRS) with Related Services||03-15-2013||06-30-2014|
|Gender Reassignment Surgery||04-01-2008||03-14-2013|
|Gender Reassignment Surgery||05-01-2006||03-31-2008|