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Kunstgeschichte Und Gender Reassignment

Gender reassignment surgery, sometimes called sex reassignment surgery, is performed to transition individuals with gender dysphoria to their desired gender.

People with gender dysphoria often feel that they were born in the wrong gender. A biological male may identify more as a female and vice versa.

Surgery is typically the last step in the physical transition process, but it is not a decision to be made lightly.

Many healthcare providers require patients to be formally diagnosed with gender dysphoria and undergo counseling to determine if they are truly ready to surgically transition.

Patients usually undergo hormone therapy first. Hormones can suppress the secondary sex characteristics of the biological gender and make them appear more like their desired sex. For instance, women take androgens and start developing facial hair. Men take estrogens and anti-androgens to look more feminine.

Surgeons may also require that patients live as their desired gender for at least one year. A man might dress as a woman traditionally does in the culture. Many men change their names and refer to themselves with female pronouns. Women transitioning to men would do the reverse.

Surgical transition may include several procedures. Males transitioning to females have their testicles and penis removed. The prostate gland may or may not be removed as well. Tissue from the penis is used to construct a vagina and clitoris. Labia – the “lips” surrounding the vagina - can be made from scrotal skin. The urethra (the tube from which urine leaves the body) is shortened.

Many biological men also have facial feminization surgery to change the appearance of their lips, eyes, nose, or Adam’s apple.

After surgery, patients use vaginal dilators to keep the new vagina open and flexible.

Surgery for females transitioning to males is more complicated and expensive. The breasts, ovaries, and uterus are removed and the vagina is closed. A penis and scrotum may be made from other tissue. In some cases, a penile implant is used. The urethra is extended so that the patient can urinate while standing.

Continued psychotherapy is recommended for most patients as they adjust to their new bodies and lifestyles.

Not all people with gender dysphoria have surgery. Some feel comfortable living as the opposite gender without medical intervention. Others find that hormone therapy is sufficient for their personal needs.

Number: 0615

Policy

Aetna considers gender reassignment surgery medically necessary when all of the following criteria are met:

  1. Requirements for mastectomy for female-to-male patients:

    1. Single letter of referral from a qualified mental health professional (see Appendix); and
    2. Persistent, well-documented gender dysphoria (see Appendix); and
    3. Capacity to make a fully informed decision and to consent for treatment; and
    4. Age of majority (18 years of age or older); and
    5. If significant medical or mental health concerns are present, they must be reasonably well controlled.

    Note that a trial of hormone therapy is not a pre-requisite to qualifying for a mastectomy.

  2. Requirements for gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male-to-female):

    1. Two referral letters from qualified mental health professionals, one in a purely evaluative role (see appendix); and
    2. Persistent, well-documented gender dysphoria (see Appendix); and
    3. Capacity to make a fully informed decision and to consent for treatment; and
    4. Age of majority (18 years or older); and
    5. If significant medical or mental health concerns are present, they must be reasonably well controlled; and
    6. Twelve months of continuous hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones)
  3. Requirements for genital reconstructive surgery (i.e., vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular prosthesis and erectile prosthesis in female to male; penectomy, vaginoplasty, labiaplasty, and clitoroplasty in male to female)

    1. Two referral letters from qualified mental health professionals, one in a purely evaluative role (see appendix); and
    2. Persistent, well-documented gender dysphoria (see Appendix); and
    3. Capacity to make a fully informed decision and to consent for treatment; and
    4. Age of majority (age 18 years and older); and
    5. If significant medical or mental health concerns are present, they must be reasonably well controlled; and
    6. Twelve months of continuous hormone therapy as appropriate to the member’s gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones); and
    7. Twelve months of living in a gender role that is congruent with their gender identity (real life experience).

Note: Blepharoplasty, body contouring (liposuction of the waist), breast enlargement procedures such as augmentation mammoplasty and implants, face-lifting, facial bone reduction, feminization of torso, hair removal, lip enhancement, reduction thyroid chondroplasty, rhinoplasty, skin resurfacing (dermabrasion, chemical peel), and voice modification surgery (laryngoplasty, cricothyroid approximation or shortening of the vocal cords), which have been used in feminization, are considered cosmetic. Similarly, chin implants, lip reduction, masculinization of torso, and nose implants, which have been used to assist masculinization, are considered cosmetic.

Note on gender specific services for the transgender community:

Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy.  Examples include:

  1. Breast cancer screening may be medically necessary for female to male trans identified persons who have not undergone a mastectomy;

  2. Prostate cancer screening may be medically necessary for male to female trans identified persons who have retained their prostate.

Aetna considers gonadotropin-releasing hormone medically necessary to suppress puberty in trans identified adolescents if they meet World Professional Association for Transgender Health (WPATH) criteria (see CPB 501 - Gonadotropin-Releasing Hormone Analogs and Antagonists).

Aetna considers the following procedures that may be performed as a component of a gender reassignment as cosmetic (not an all-inclusive list) (see also CPB 0031 - Cosmetic Surgery):

  • Abdominoplasty
  • Blepharoplasty
  • Brow lift
  • Calf implants
  • Cheek/malar implants
  • Chin/nose implants
  • Collagen injections
  • Construction of a clitoral hood
  • Drugs for hair loss or growth
  • Forehead lift
  • Jaw reduction (jaw contouring)
  • Hair removal (e.g., electrolysis, laser hair removal) 
  • Hair transplantation
  • Lip reduction
  • Liposuction
  • Mastopexy
  • Neck tightening
  • Nipple reconstruction
  • Nose implants
  • Pectoral implants
  • Removal of redundant skin
  • Rhinoplasty
  • Voice therapy/voice lessons.

Background

Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between an individual’s gender identity and the gender assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). A diagnosis of gender dysphoria requires a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. This condition may cause clinically significant distress or impairment in social, occupational or other important areas of functioning.  

Gender reassignment surgery is performed to change primary and/or secondary sex characteristics. For male to female gender reassignment, surgical procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty) and cosmetic surgery (breast implants, facial reshaping, rhinoplasty, abdominoplasty, thyroid chondroplasty (laryngeal shaving), voice modification surgery (vocal cord shortening), hair transplants) (Day, 2002). For female to male gender reassignment, surgical procedures may include mastectomy, genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, and cosmetic procedures to enhance male features such as pectoral implants and chest wall recontouring (Day, 2002).

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 (Coleman, et al., 2011). 

In addition to hormone therapy and gender reassignment surgery, psychological adjustments are necessary in affirming sex. Treatment should focus on psychological adjustment, with hormone therapy and gender reassignment surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Mental health care may need to be continued after gender reassignment surgery. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the trans identified person and the support from family, friends, employers and the medical profession.

Nakatsuka (2012) noted that the 3rd versions of the guideline for treatment of people with gender dysphoria (GD) of the Japanese Society of Psychiatry and Neurology recommends that feminizing/masculinizing hormone therapy and genital surgery should not be carried out until 18 years old and 20 years old, respectively.  On the other hand, the 6th (2001) and the 7th (2011) versions of the standards of care for the health of transsexual, transgender, and gender non-conforming people of World Professional Association for Transgender Health (WPATH) recommend that transgender adolescents (Tanner stage 2, [mainly 12 to 13 years of age]) are treated by the endocrinologists to suppress puberty with gonadotropin-releasing hormone (GnRH) agonists until age 16 years old, after which cross-sex hormones may be given.  A questionnaire on 181 people with GID diagnosed in the Okayama University Hospital (Japan) showed that female to male (FTM) trans identified individuals hoped to begin masculinizing hormone therapy at age of 15.6 +/- 4.0 (mean +/- S.D.) whereas male to female (MTF) trans identified individuals hoped to begin feminizing hormone therapy as early as age 12.5 +/- 4.0, before presenting secondary sex characters.  After confirmation of strong and persistent trans gender identification, adolescents with GD should be treated with cross-gender hormone or puberty-delaying hormone to prevent developing undesired sex characters.  These treatments may prevent transgender adolescents from attempting suicide, suffering from depression, and refusing to attend school. 

Spack (2013) stated that GD is poorly understood from both mechanistic and clinical standpoints.  Awareness of the condition appears to be increasing, probably because of greater societal acceptance and available hormonal treatment.  Therapeutic options include hormone and surgical treatments but may be limited by insurance coverage because costs are high.  For patients seeking MTF affirmation, hormone treatment includes estrogens, finasteride, spironolactone, and GnRH analogs.  Surgical options include feminizing genital and facial surgery, breast augmentation, and various fat transplantations.  For patients seeking a FTM gender affirmation, medical therapy includes testosterone and GnRH analogs and surgical therapy includes mammoplasty and phalloplasty.  Medical therapy for both FTM and MTF can be started in early puberty, although long-term effects are not known.  All patients considering treatment need counseling and medical monitoring.

Leinung and colleagues (2013) noted that the Endocrine Society's recently published clinical practice guidelines for the treatment of transgender persons acknowledged the need for further information on transgender health.  These investigators reported the experience of one provider with the endocrine treatment of transgender persons over the past 2 decades. Data on demographics, clinical response to treatment, and psychosocial status were collected on all transgender persons receiving cross-sex hormone therapy since 1991 at the endocrinology clinic at Albany Medical Center, a tertiary care referral center serving upstate New York.  Through 2009, a total 192 MTF and 50 FTM transgender persons were seen.  These patients had a high prevalence of mental health and psychiatric problems (over 50 %), with low rates of employment and high levels of disability.  Mental health and psychiatric problems were inversely correlated with age at presentation.  The prevalence of gender reassignment surgery was low (31 % for MTF).  The number of persons seeking treatment has increased substantially in recent years.  Cross-sex hormone therapy achieves very good results in FTM persons and is most successful in MTF persons when initiated at younger ages.  The authors concluded that transgender persons seeking hormonal therapy are being seen with increasing frequency.  The dysphoria present in many transgender persons is associated with significant mood disorders that interfere with successful careers.  They stated that starting therapy at an earlier age may lessen the negative impact on mental health and lead to improved social outcomes.

Meyer-Bahlburg (2013) summarized for the practicing endocrinologist the current literature on the psychobiology of the development of gender identity and its variants in individuals with disorders of sex development or with transgenderism.  Gender reassignment remains the treatment of choice for strong and persistent gender dysphoria in both categories, but more research is needed on the short-term and long-term effects of puberty-suppressing medications and cross-sex hormones on brain and behavior.

Note on Nipple Reconstruction:

Aetna considers nipple reconstruction, as defined by the American Medical Association (AMA) Current Procedural Terminology (CPT) code 19350, cosmetic/not medically necessary for mastectomy for female to male gender reassignment. Performance of a mastectomy for gender reassignment does not involve a nipple reconstruction as defined by CPT code 13950. 

Some have cited breast reconstruction surgery for breast cancer, i.e., recreation of a breast after mastectomy, as support for coverage of nipple reconstruction. Mastectomy for female to male gender reassignment surgery, however, involves mastectomy without restoration of the breast. There are important differences between a mastectomy for breast cancer and a mastectomy for gender reassignment. The former requires careful attention to removal of all breast tissue to reduce the risk of cancer. By contrast, careful removal of all breast tissue is not essential in mastectomy for gender reassignment. 

In mastectomy for gender reassignment, the nipple areola complex typically can be preserved. There is no routine indication for nipple reconstruction as defined by CPT code 19350, the exceptions being unusual cases where construction of a new nipple may be necessary in persons with very large and ptotic breasts. See, e.g., Bowman, et al., 2006). 

Some have justified routinely billing CPT code 19350 for nipple reconstruction code for mastectomy for gender reassignment based upon the frequent need to reduce the size of the areola to give it a male appearance. However, the nipple reconstruction as defined by CPT code 19350 describes a much more involved procedure than areola reduction. The typical patient vignette for CPT code 19350, according to the AMA, is as follows: “The patient is measured in the standing position to ensure even balanced position for a location of the nipple and areola graft on the right breast.  Under local anesthesia, a Skate flap is elevated at the site selected for the nipple reconstruction and constructed.  A full-thickness skin graft is taken from the right groin to reconstruct the areola.  The right groin donor site is closed primarily in layers.”  

Aetna will consider allowing modifier -22 to be appended to the mastectomy CPT code when this procedure is performed for gender reassignment to allow additional reimbursement for the extra work that may be necessary to reshape the nipple and create an aesthetically pleasing male chest.  CPT code 13950 does not describe the work that that is being done, because that code describes the actual construction of a new nipple. The CPT defines modifier 22 as "Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required)." 

Thus, Aetna considers nipple reconstruction, as defined by CPT code 19350, as cosmetic/not medically necessary for mastectomy for female to male gender reassignment, and that appending modifier 22 to the mastectomy code would more accurately reflect the extra work that may typically be necessary to obtain an aesthetically pleasing result. 

Appendix

DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents:

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by two or more of the following:

  1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics)
  2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
  3. A strong desire for the primary and/or secondary sex characteristics of the other gender
  4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
  5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
  6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Format for referral letters from Qualified Health Professional: (From SOC-7)

  1. Client’s general identifying characteristics; and
  2. Results of the client’s psychosocial assessment, including any diagnoses; and
  3. The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date; and
  4. An explanation that the WPATH criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery; and
  5. A statement about the fact that informed consent has been obtained from the patient; and
  6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

Note:  There is no minimum duration of relationship required with mental health professional.  It is the professional’s judgment as to the appropriate length of time before a referral letter can appropriately be written.  A common period of time is three months, but there is significant variation in both directions.  When two letters are required, the second referral is intended to be an evaluative consultation, not a representation of an ongoing long-term therapeutic relationship, and can be written by a medical practitioner of sufficient experience with gender dysphoria.

Note: Evaluation of candidacy for sex reassignment surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. Please check benefit plan descriptions.

Characteristics of a Qualified Mental Health Professional: (From SOC-7):

  1. Master’s degree or equivalent in a clinical behavioral science field granted by an institution accredited by the appropriate national accrediting board.  The professional should also have documented credentials from the relevant licensing board or equivalent; and
  2. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Disease for diagnostic purposes; and
  3. Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria; and
  4. Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria; and
  5. Continuing education in the assessment and treatment of gender dysphoria.  This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria. 

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

CPT codes covered if selection criteria are met:

19301, 19303 - 19304Mastectomy
53430Urethroplasty, reconstruction of female urethra
54125Amputation of penis; complete
54400 - 54417Penile prosthesis
54520Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach
54660Insertion of testicular prosthesis (separate procedure)
54690Laparoscopic, surgical; orchiectomy
55175Scrotoplasty; simple
55180     complicated
55970Intersex surgery; male to female [a series of staged procedures that includes male genitalia removal, penile dissection, urethral transposition, creation of vagina and labia with stent placement]
55980    female to male [a series of staged procedures that include penis and scrotum formation by graft, and prostheses placement]
56625Vulvectomy simple; complete
56800Plastic repair of introitus
56805Clitoroplasty for intersex state
56810Perineoplasty, repair of perineum, nonobstetrical (separate procedure)
57106 - 57107, 57110 - 57111Vaginectomy
57291 - 57292Construction of artificial vagina
57335Vaginoplasty for intersex state
58150, 58180, 58260 - 58262, 58275 - 58291, 58541 - 58544, 58550 - 58554 Hysterectomy
58570 - 58573Laparoscopy, surgical, with total hysterectomy
58661Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
58720Salpingo-oophorectomy, complete or partial, unilateral or bilateral

CPT codes not covered for indications listed in the CPB [considered cosmetic]:

11950 - 11954Subcutaneous injection of filling material (e.g., collagen)
15200Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less [nipple reconstruction]
15775Punch graft for hair transplant; 1 to 15 punch grafts
15776Punch graft for hair transplant; more than 15 punch grafts
15780 - 15787Dermabrasion
15788 - 15793Chemical peel
15820 - 15823Blepharoplasty
15824 - 15828Rhytidectomy [face-lifting]
15830 - 15839Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
15876 - 15879Suction assisted lipectomy
17380 Electrolysis epilation, each 30 minutes
19316 Mastopexy
19318Reduction mammaplasty
19324 - 19325Mammaplasty, augmentation
19340Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19342Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19350 Nipple/areola reconstruction
21087Nasal prosthesis
21120 - 21123Genioplasty
21125 - 21127Augmentation, mandibular body or angle; prosthetic material or with bone graft, onlay or interpositional (includes obtaining autograft)
21193Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft
21194    with bone graft (includes obtaining graft)
21195Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation
21196    with internal rigid fixation
21208Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)
21210Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
21270Malar augmentation, prosthetic material
30400 - 30420Rhinoplasty; primary
30430 - 30450Rhinoplasty; secondary
67900Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
92507Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, two or more individuals

Other CPT codes related to the CPB:

11980Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)
+90785Interactive complexity (List separately in addition to the code for primary procedure)
90832 - 90838Psychotherapy
96372Therapeutic, prophylactic, or diagnostic injection (specify substance of drug); subcutaneous or intramuscular

HCPCS codes covered if selection criteria are met:

C1813Prosthesis, penile, inflatable
C2622Prosthesis, penile, non-inflatable
J1950Injection, leuprolide acetate (for depot suspension), per 3.75 mg
J9202Goserelin acetate implant, per 3.6 mg
J9217Leuprolide acetate (for depot suspension), 7.5 mg
J9218Leuprolide acetate, per 1 mg
J9219Leuprolide acetate implant, 65 mg
S0189Testosterone pellet, 75 mg

HCPCS codes not covered for indications listed in the CPB :

G0153Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes
S9128Speech therapy, in the home, per diem

ICD-10 codes covered if selection criteria are met:

F64.0 - F64.1Transexualism and dual role transvestism
F64.8Other gender identity disorders
F64.9Gender identity disorder, unspecified
Z87.890Personal history of sex reassignment

ICD-10 codes not covered for indications listed in the CPB:

F01.50 - F63.9, F65.0 - F99Mental disorders [other than adult gender identity disorder]
F64.2Gender identity disorder of childhood
Q56.0 - Q56.4Indeterminate sex and pseudohermaphroditism
Q90.0 - Q99.9Chromosomal anomalies, not elsewhere classified
R37Sexual dysfunction, unspecified

The above policy is based on the following references:

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