Medical Review Criteria Gender Reassignment Services

Transcription

1 Medical Review Criteria Gender Reassignment Services Effective Date: May 12, 2016 Subject: Gender Reassignment Services for Fully-Insured Transgender Subscribers and Dependents Policy: HPHC covers specific Gender Reassignment Surgeries (GRS) and related clinician visits and medications that are medically necessary and prescribed or recommended (by qualified practitioners) for eligible members (i.e., members enrolled in plans that include GRS benefits) diagnosed with Gender Dysphoria. 1 Covered procedures must be performed by qualified providers trained in treating individuals with Gender Dysphoria. Members with questions about HPHC s GRS benefits and/or prior authorization processes should contact HPHC s Member Services Department at HPHC also covers retrieval, cryopreservation, and storage (up to one year) of sperm or eggs when documentation confirms an eligible member with Gender Dysphoria will be undergoing Gender Reassignment treatment that is likely to result in infertility. Authorization: Prior authorization is required for the following Gender Reassignment services: For male to female transition: Augmentation Mammaplasty Clitoroplasty Colovaginoplasty Facial feminization procedures (coverage limited to forehead contouring, mandible/jaw contouring, rhinoplasty and chondrolaryngoplasty) Labiaplasty Orchiectomy Penectomy Rhinoplasty Vaginoplasty For female to male transition: Colpectomy Hysterectomy Mastectomy (bilateral) Metoidoplasty Phalloplasty Rhinoplasty Salpingo-oophrectomy Scrotoplasy with placement of testicular prostheses Urethroplasty Prior authorization is also required for retrieval, cryopreservation, and storage (up to one year) of sperm or eggs. Criteria: Gender Reassignment services are authorized when letters from clinicians (i.e. physician(s) and Mental Health Professional) responsible for hormone therapies and/or other related transitional care confirm ALL the following 2 : 1. Member age 18 years or older has been diagnosed, by an appropriately trained Mental Health Professional 3 (MHP), with Gender Dysphoria; 2. Member wishes to make his/her body as congruent as possible with the preferred gender through surgery and hormone replacement; 1 Coverage includes treatment of medical complications related to authorized GRS surgeries. 2 HPHC requires at least two letters from treating clinicians. Members may provide these to support the authorization process. 3 Mental health services are administered by Optum dba United Behavioral Health (UBH). For questions about benefits and providers call Gender Reassignment Surgery Page 1 of 6

2 3. GRS has been recommended by treating physician(s) and MHP; 4. The physician has medically cleared the individual for GRS. Retrieval, cryopreservation, and storage (up to one year) of sperm or eggs (as appropriate) is authorized when documentation confirms the member with Gender Dysphoria will be undergoing Gender Reassignment treatment that is likely to result in infertility. (The member is not required to meet HPHC s criteria for Infertility Services but the plan must include infertility benefits.) Documentation must confirm that member and provider(s) have discussed the impact of Gender Reassignment treatment on fertility and family planning Exclusions: HPHC does not cover Gender Reassignment services when criteria above are not met. HPHC does not cover the following procedures when performed for the purpose of gender reassignment: Blepharoplasty Collagen injections Electrolysis Face-lifting of any kind (i.e. rhytidectomy) Facial implants or injections Hair removal Hair transplantation Laryngoplasty Lip reduction/enhancement Liposuction Removal of redundant skin Silicone injections (e.g., for breast enlargement) Voice modification surgery In addition, HPHC does not cover or reimburse for travel expenses incurred in relation to GRS Related Codes: Code lists may not include all GRS-related services. Male to Female Transition Gender Reassignment Surgery Facial Feminization Surgery Intersex surgery, male to female Osteoplasty, facial bones; reduction Genioplasty, augmentation (autograft, allograft, prosthetic implant) Genioplasty; sliding osteotomy, single piece Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g. wedge excision or bone wedge reversal of asymmetrical chin) Genioplasty; sliding, augmentation with interpositional bone grafts (including obtaining autografts) Augmentation, mandibular body or angle; prosthetic material Augmentation, mandibular body or angle, with bone graft, onlay or interpostitional (includes obtaining autograft) Reduction forehead; contouring only Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) Reduction forehead; contouring and setback of anterior frontal sinus wall Gender Reassignment Surgery Page 2 of 6

3 Male to Female Transition Trachea shaving Penectomy and related procedures Orchiectomy Vaginoplasty Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages and/or elevation of nasal tip Rhinoplasty, primary; including major septal repair Rhinoplasty, secondary; minor revision (small amount of nasal tip work) Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) Tracheoplasty; cervical Laryngoplasty, cricoid split Amputation of penis; partial Amputation of penis; complete Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra Urethroplasty, 2-stage reconstruction or repair off prostatic or membranous urethra; first stage Urethroplasty, 2-stage reconstruction or repair off prostatic or membranous urethra; second stage Urethroplasty, reconstruction of female urethra Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach Laparoscopy, surgical; orchiectomy Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed Plastic repair of introitus Construction of artificial vagina; without graft Construction of artificial vagina; with graft Revision (including removal) of prosthetic vaginal graft; vaginal approach Revision (including removal) of prosthetic vaginal graft; open abdominal approach Vaginoplasty for intersex state Revision (including removal) of prosthetic vaginal graft, laparoscopic approach Labiaplasty Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm Plastic repair of introitus Unlisted procedure, female genital system (nonobstetrical)** Clitoroplasty Clitoroplasty for intersex state (female procedure) Breast Augmentation Mammaplasty, augmentation; without prosthetic implant Mammaplasty, augmentation, with prosthetic implant Nipple/areola reconstruction Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion Revision of reconstructed breast Female to Male Transition Gender Reassignment Surgery Intersex surgery, female to male Gender Reassignment Surgery Page 3 of 6

4 Female to Male Transition Mastectomy Hysterectomy and related procedures Metoidioplasty Mastectomy, simple, complete Mastectomy, subcutaneous Nipple/areola reconstruction Vulvectomy simple; complete Perineoplasty, repair of perineum, nonobstetrical Vaginectomy, partial removal of vaginal wall Vaginectomy, complete removal of vaginal wall Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or with removal of ovary(s) Vaginal hysterectomy, for uterus 250 grams or less; Vaginal hysterectomy, for uterus 250 grams or less, with removal of Vaginal hysterectomy, with total or partial vaginectomy; Vaginal hysterectomy, for uterus greater than 250 g; Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure): with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) Oophorectomy, partial or total, unilateral or bilateral Unlisted procedure; male genital system** Gender Reassignment Surgery Page 4 of 6

5 Female to Male Transition Phalloplasty and related procedures Rhinoplasty Additional Procedures Tissues expansion Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra Urethroplasty, 2-stage reconstruction or repair off prostatic or membranous urethra; first stage Urethroplasty, 2-stage reconstruction or repair off prostatic or membranous urethra; second stage Urethroplasty, reconstruction of female urethra Insertion of penile prosthesis; noninflatable (semi-rigid) Insertion of penile prosthesis; inflatable (self-contained) Insertion of multi-component inflatable penile prosthesis, including placement of pump, cylinders and reservoir Insertion of testicular prosthesis (separate procedure) Scrotoplasty; simple Scrotoplasty; complicated Unlisted procedure; male genital system** Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages and/or elevation of nasal tip Rhinoplasty, primary; including major septal repair Rhinoplasty, secondary; minor revision (small amount of nasal tip work) Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) Rhinoplasty, secondary; major revision (nasal tip work and osteotomies Accepted Codes Insertion of tissue expanders(s) for other than breast, including subsequent expansion Replacement of tissue expander with permanent prosthesis Removal of tissue expander(s) without insertion of prosthesis Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, axillae, genitalia, hands, and/or feet; defect 10 sq.cm or less Adjacent tissue transfer or rearrangement, forehead, cheeks, chin mouth, neck, axillae, genitalia, hands, and/or feet; defect 10.1 sq. cm to 30 sq. cm ** Procedures billed with an unlisted code pend for medical review; additional documentation must accompany submitted claim. Revision History: Approved by UMCPC: 4/27/16 Revised: 7/14; 2/15; 4/15; 11/15; 4/16 Initiated: 2013 Date Summary of Changes 3/16 Clarified documentation requirements. Corrected coding. 11/15 Updated policy language Gender Reassignment Surgery Page 5 of 6

6 2/15 Clarified coding, updated policy language. Added language re: coverage of retrieval, cryopreservation and storage of sperm or eggs. References: WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, Seventh Version: Gender Reassignment Surgery Page 6 of 6