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 1-888-333-4742. 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 1-866-808-5062. Gender Reassignment Surgery Page 1 of 6
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 55970 Intersex surgery, male to female 21209 Osteoplasty, facial bones; reduction 21120 Genioplasty, augmentation (autograft, allograft, prosthetic implant) 21121 Genioplasty; sliding osteotomy, single piece 21122 Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g. wedge excision or bone wedge reversal of asymmetrical chin) 21123 Genioplasty; sliding, augmentation with interpositional bone grafts (including obtaining autografts) 21125 Augmentation, mandibular body or angle; prosthetic material 21127 Augmentation, mandibular body or angle, with bone graft, onlay or interpostitional (includes obtaining autograft) 21137 Reduction forehead; contouring only 21138 Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) 21139 Reduction forehead; contouring and setback of anterior frontal sinus wall Gender Reassignment Surgery Page 2 of 6
Male to Female Transition Trachea shaving Penectomy and related procedures Orchiectomy Vaginoplasty 30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip 30401 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages and/or elevation of nasal tip 30420 Rhinoplasty, primary; including major septal repair 30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work) 30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) 30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) 31750 Tracheoplasty; cervical 31587 Laryngoplasty, cricoid split 54120 Amputation of penis; partial 54125 Amputation of penis; complete 53415 Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra 53420 Urethroplasty, 2-stage reconstruction or repair off prostatic or membranous urethra; first stage 53425 - Urethroplasty, 2-stage reconstruction or repair off prostatic or membranous urethra; second stage 53430 Urethroplasty, reconstruction of female urethra 54520 Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach 54690 Laparoscopy, surgical; orchiectomy 55586 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed 56800 Plastic repair of introitus 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 57335 Vaginoplasty for intersex state 57426 Revision (including removal) of prosthetic vaginal graft, laparoscopic approach Labiaplasty 14301 Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm 56800 Plastic repair of introitus 58999 - Unlisted procedure, female genital system (nonobstetrical)** Clitoroplasty 56805 Clitoroplasty for intersex state (female procedure) Breast Augmentation 19324 Mammaplasty, augmentation; without prosthetic implant 19325 Mammaplasty, augmentation, with prosthetic implant 19350 Nipple/areola reconstruction 19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion 19380 Revision of reconstructed breast Female to Male Transition Gender Reassignment Surgery 55980 Intersex surgery, female to male Gender Reassignment Surgery Page 3 of 6
Female to Male Transition Mastectomy Hysterectomy and related procedures Metoidioplasty 19303 Mastectomy, simple, complete 19304 Mastectomy, subcutaneous 19350 Nipple/areola reconstruction 56625 Vulvectomy simple; complete 56810 Perineoplasty, repair of perineum, nonobstetrical 57106 Vaginectomy, partial removal of vaginal wall 57110 Vaginectomy, complete removal of vaginal wall 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) 58180 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or with removal of ovary(s) 58260 Vaginal hysterectomy, for uterus 250 grams or less; 58262 Vaginal hysterectomy, for uterus 250 grams or less, with removal of 58275 Vaginal hysterectomy, with total or partial vaginectomy; 58290 Vaginal hysterectomy, for uterus greater than 250 g; 58291 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) 58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; 58542 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) 58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; 58544 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) 58550 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; 58552 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) 58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; 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) 58661 Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure): with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy 58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) 58940 Oophorectomy, partial or total, unilateral or bilateral 55899 Unlisted procedure; male genital system** Gender Reassignment Surgery Page 4 of 6
Female to Male Transition Phalloplasty and related procedures Rhinoplasty Additional Procedures Tissues expansion 53415 Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra 53420 Urethroplasty, 2-stage reconstruction or repair off prostatic or membranous urethra; first stage 53425 - Urethroplasty, 2-stage reconstruction or repair off prostatic or membranous urethra; second stage 53430 Urethroplasty, reconstruction of female urethra 54400 Insertion of penile prosthesis; noninflatable (semi-rigid) 54401 Insertion of penile prosthesis; inflatable (self-contained) 54405 Insertion of multi-component inflatable penile prosthesis, including placement of pump, cylinders and reservoir 54660 Insertion of testicular prosthesis (separate procedure) 55175 Scrotoplasty; simple 55180 Scrotoplasty; complicated 55899 Unlisted procedure; male genital system** 30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip 30401 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages and/or elevation of nasal tip 39420 Rhinoplasty, primary; including major septal repair 30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work) 30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) 30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies Accepted Codes 11960 Insertion of tissue expanders(s) for other than breast, including subsequent expansion 11970 Replacement of tissue expander with permanent prosthesis 11971 Removal of tissue expander(s) without insertion of prosthesis 14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, axillae, genitalia, hands, and/or feet; defect 10 sq.cm or less 14041 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
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: http://www.wpath.org/ Gender Reassignment Surgery Page 6 of 6