Cigna Gender Dysphoria Treatment - (0266) Form

The following Coverage Policy applies to health benefit plans administered by Cigna Companies.

Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients.

Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based.

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Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies.

In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of:

1. the terms of the applicable benefit plan document in effect on the date of service;
2. any applicable laws/regulations;
3. any relevant collateral source materials including Coverage Policies and;
4. the specific facts of the particular situation.

Each coverage request should be reviewed on its own merits. Medical directors are expected to exercise clinical judgment where appropriate and have discretion in making individual coverage determinations.

Where coverage for care or services does not depend on specific circumstances, reimbursement will only be provided if a requested service(s) is submitted in accordance with the relevant criteria outlined in the applicable Coverage Policy, including covered diagnosis and/or procedure code(s). Reimbursement is not allowed for services when billed for conditions or diagnoses that are not covered under this Coverage Policy (see “Coding Information” below).

When billing, providers must use the most appropriate codes as of the effective date of the submission. Claims submitted for services that are not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered.

Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines.

In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

This Coverage Policy addresses treatment of gender dysphoria.

Gender dysphoria is a condition commonly described as a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics; it has been described by the American Psychiatric Association (2021) as “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity”.

The terms gender reassignment, gender confirming, and gender affirming are commonly used interchangeably to describe the processes that an individual may undergo to transition to the desired gender identity.

Coverage Policy

Coverage for treatment of gender dysphoria varies across plans. Coverage of drugs for hormonal therapy, as well as whether the drug is covered as a medical or a pharmacy benefit, varies across plans. Refer to the customer’s benefit plan document for coverage details.

In addition, coverage for treatment of gender dysphoria, including gender reassignment surgery and related services may be governed by state and/or federal mandates.^{1 2} Some states require coverage of health services specific to treatment of gender dysphoria which may be more or less restrictive than this coverage policy. Please access applicable STATE SPECIFIC GUIDELINES prior to consideration of coverage for services related to treatment of gender dysphoria.

1 New York regulated benefit plans do not include exclusions or plan language that limit coverage.
2 Washington State regulated benefit plans are subject to mandated coverage criteria.

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Unless otherwise specified in a benefit plan, the following conditions of coverage apply for treatment of gender dysphoria and/or gender reassignment surgery and related procedures, including all applicable benefit limitations, precertification, or other medical necessity criteria.

Medically necessary treatment for an individual with gender dysphoria, including nonbinary individuals diagnosed with gender dysphoria, may include ANY of the following services:

• Behavioral health services, including but not limited to, counseling for gender dysphoria and related psychiatric conditions (e.g., anxiety, depression).
• Hormonal therapy, including but not limited to androgens, anti-androgens, GnRH analogues*, estrogens, and progestins (Prior authorization requirements may apply).
  Note: If use in adolescents, individual should have reached Tanner stage 2 of puberty prior to receiving GnRH agonist therapy.
• Laboratory testing to monitor prescribed hormonal therapy.
• Age-related, gender-specific services, including but not limited to preventive health, as appropriate to the individual’s biological anatomy (e.g., cancer screening [e.g., cervical, breast, prostate], treatment of a prostate medical condition)

Gender reassignment and related surgery (see below).

Gender Reassignment Surgery

Gender reassignment surgery, also known as gender affirmation surgery or gender confirmation surgery, is considered medically necessary treatment of gender dysphoria when the following criteria are met.

• For New York regulated benefit plans (e.g., insured): case-by-case review by a medical director for individuals under the age of 18 years of age will be given.
• California fully insured plans are not subject to utilization management for gender dysphoria treatment, effective 10/25/2023.

For reconstructive chest surgery ANY of the following criteria:

• For initial mastectomy* for an individual ">= age 17 years one letter of support from a qualified mental health professional, who has evaluated the individual for gender dysphoria and gives unequivocal support for the procedure being proposed.
• For initial mastectomy* for an individual age 15 years to < age 17 years BOTH of the following:
  • Parental/guardian consent, when applicable
  • Two separate letters of support, each from an independent mental health provider experienced in adolescent mental health and the diagnosis and treatment of childhood gender dysphoria. Each mental health evaluation must confirm a diagnosis of gender dysphoria, confirm it is marked and sustained over time (e.g., two years), address any mental health comorbidities, and document the individual’s emotional and cognitive maturity necessary to provide informed consent.
• Note: Initial mastectomy as part of gender reassignment surgery for an individual < than age 15 years is considered not medically necessary.

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• Breast augmentation for an individual age 18 years and older one letter of support from a qualified mental health professional, who has evaluated the individual for gender dysphoria and gives unequivocal support for the procedure being proposed.

NOTE: The Women’s Health and Cancer Rights Act (WHCRA), 29 U.S. Code § 1185b requires coverage of certain post-mastectomy services related to breast reconstruction and treatment of physical complications from mastectomy including nipple-areola reconstruction.

• For hysterectomy, salpingo-oophorectomy, orchiectomy for an individual age 18 years or older:
  • recommendation for sex reassignment surgery (i.e., genital surgery) by a qualified mental health professional who has evaluated the individual for gender dysphoria and gives unequivocal clearance for the procedure being proposed.
• For reconstructive genital surgery for an individual age 18 years or older:
  • recommendation for sex reassignment surgery (i.e., genital surgery) by a qualified mental health professional who has evaluated the individual for gender dysphoria and gives unequivocal clearance for the procedure being proposed.

Table 1: Gender Reassignment Surgery: Covered Under Standard Benefit Plan Language

The procedures listed below are considered medically necessary under standard benefit plan language when the above listed criteria for gender reassignment surgery have been met, unless specifically excluded in the benefit plan language.

Procedure

• Female to Male reconstructive genital surgery:
• Intersex surgery, female to male (may involve staged procedures to form a penis and scrotum using pedicle flaps and free-skin graft, insertion of prostheses and closure of the vagina)
• Vaginectomy/colpectomy
• Vulvectomy
• Metoidioplasty
• Phalloplasty (may include nerve transposition of medial or lateral antebrachial nerve)
• Hair removal by electrolysis of donor site tissue to be used for phalloplasty, limited to eight 30-minute timed units per day
• Penile prosthesis (noninflatable / inflatable), including surgical correction of malfunctioning pump, cylinders, or reservoir
• Urethroplasty /urethromeatoplasty
• Hysterectomy and salpingo-oophorectomy
• Scrotoplasty
• Insertion of testicular prosthesis
• Replacement of tissue expander with permanent prosthesis testicular insertion
• CPT / HCPCS codes (This list may not be all inclusive)
• 55980
• 57110
• 56625
• 58999
• 58999, 64856
• 17380
• 54400, 54401, 54405, C1813, C2622
• 53410, 53430, 53450
• 58150, 58260, 58262, 58291, 58552, 58554, 58571, 58573, 58661
• 55175, 55180
• 54660
• 11970

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Procedure CPT / HCPCS codes (This list may not be all inclusive)

• Testicular expanders, including replacement with prosthesis, testicular prosthesis
• 11960, 11970, 11971, 54660
• Flaps, grafts, and/or tissue transfer directly related to a genital reconstructive procedure
• 14041, 14301, 14302, 15100, 15101, 15738, 15757
• Female to Male reconstructive chest surgery:
• Initial mastectomy
• Nipple-areola reconstruction (related to mastectomy or post mastectomy reconstruction)
• Free full thickness graft (for nipple)
• Breast reduction
• Pectoral implants
• Male to Female reconstructive genital surgery:
• Intersex surgery, male to female (may involve staged procedures to remove portions of male genitalia and form female external genitals such as penectomy, orchiectomy, vaginoplasty, clitoroplasty, urethroplasty, creation of a vagina)
• Vaginoplasty, (e.g, construction of vagina with/without graft, colovaginoplasty, penile inversion)
• Hair removal by electrolysis of donor site tissue to be used to line the vaginal canal for vaginoplasty, limited to eight 30-minute timed units per day
• Penectomy
• Vulvoplasty (e.g., labiaplasty, clitoroplasty, penile skin inversion)
• Urethroplasty
• Repair of introitus
• Coloproctostomy
• Orchiectomy
• Flaps, grafts, and/or tissue transfer directly related to a genital reconstructive procedure
• Male to Female reconstructive chest surgery:
• Initial breast reconstruction including augmentation with implants
• 19303
• 19350*
• 15200, 15201
• 19318
• L8600, 17999
• 55970
• 15240, 15241, 57291, 57292, 57335
• 17380
• 54125
• 56620, 56805
• 53430
• 56800
• 44145, 55899
• 54520, 54690
• 14301, 14302, 15750
• Fat grafting (alone, or with implant based feminization)
• 15771-15772 (when specific to breast), 19325, 19340, 19342, C1789

Note: CPT 19318 (breast reduction) includes the work necessary to reposition and reshape the nipple and areola. Therefore, CPT 19350 (nipple and areola reconstruction) is considered integral to CPT 19318. Thus, these two codes cannot be billed together for “mastectomy” for the purpose of gender reassignment. However, 19350 would be covered if requested along with 19303 as per the federal mandate.

Table 2: Gender Reassignment Surgery: Other Procedures

Head and/or neck feminization/masculinization procedures listed below are considered not medically necessary under standard benefit plan language. However, some benefit plans may expressly cover some or all of the procedures listed below for gender dysphoria treatment. In addition, please access applicable STATE SPECIFIC GUIDELINES prior to consideration of coverage for services listed in Table 2 related to treatment of gender dysphoria.

Head and/or Neck Feminization/Masculinization Procedures

CPT/HCPCS Code

• Blepharoplasty
• Brow lift
• Cheek/malar implants
• Chin/nose implants, chin recontouring
• Collagen injections, limited to facial
• Face lift
• Forehead reduction and contouring
• Facial bone reduction (osteoplasty)
• Jaw reduction, contouring, augmentation
• Laryngoplasty
• Lip lift and lip filling
• Rhinoplasty
• Skin resurfacing (e.g., dermabrasion, chemical peels) limited to facial
• Thyroid reduction chondroplasty
• Neck tightening
• Electrolysis other than when performed pre-vaginoplasty as outlined above (i.e., face, neck) and limited to eight 30 minute timed units per day
• Suction assisted lipoplasty, lipofilling, and/or liposuction (i.e., head, neck)
• Voice therapy/voice lessons
• Voice modification surgery

15820, 15821, 15822, 15823
67900
17999
21210, 21270, 30400, 30410, 30420, 30430
30435, 30450
11950, 11951, 11952, 11954
15824, 15825, 15826, 15828, 15829
21137, 21138, 21139, 21172, 21179, 21180
21188, 21208, 21209
21025, 21120, 21121, 21122, 21123, 21125, 21127, 21193
31599
40799
21210, 21270, 30400, 30410, 30420, 30430, 30435, 30450
15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793
31750
15825
17380
15839, 15876
92507
31599, 31899

Table 3: Services Not Covered for Gender Reassignment

Not Covered Procedures

CPT/HCPCS Code

• Abdominoplasty
• Calf implants
• Hair transplantation
• Suction assisted lipoplasty, lipofilling, and/or liposuction (i.e., body contouring of waist, panniculectomy, thigh, leg, hip, buttock, arm)
• Removal of redundant skin

15847
17999
15775, 15776
15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15877, 15878, 15879
15830, 15832, 15833, 15834, 15835, 15836
15837, 15838

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Not Covered Procedures

CPT/HCPCS Code

• Neck tightening, when not part of a covered facial feminization procedure
• Lip enhancement, when not part of a covered facial feminization procedure
• Buttock lift/gluteal augmentation
• Hair removal (e.g., electrolysis), other than as noted above and/or greater than eight 30-minute timed units
• Laser hair removal, for any indication

15825
40799
17999
17380
17999

General Background

Gender dysphoria is described by the American Psychiatric Association (2021) as psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity. Gender identity refers to one’s psychological sense of their gender, whereas gender expression refers to the outward manner in which one presents their gender. The causes of gender dysphoria and the developmental factors associated with them are not well-understood.

Treatment of individuals with gender dysphoria varies, with some treatments involving a change in gender expression or body modification. Gender binary refers to two categories of gender: male and female. “Transgender” is a term that describes an individual whose gender identity does not align with the gender assigned at birth but may also refer to an individual whose sense of gender identity is binary and not traditionally associated with that assigned at birth (APA, 2021). The term “transsexual” refers to an individual whose gender identity is not congruent with their genetic and/or assigned sex and usually seeks hormone replacement therapy (HRT) and possibly gender-affirmation surgery to feminize or masculinize the body and who may live full-time in the cross-gender role. Transsexualism is a form of gender dysphoria. Other differential diagnoses include, but are not limited to, partial or temporary disorders as seen in adolescent crisis, transvestitism, refusal to accept a homosexual orientation, psychotic misjudgments of gender identity and severe personality disorders.

For children and adolescents, the mental health professional should also be trained in child and adolescent developmental psychopathology.

Once the individual is evaluated, the mental health professional provides documentation and formal recommendations to medical and surgical specialists. Documentation for hormonal and/or surgery should be comprehensive and include the extent to which eligibility criteria have been met (i.e., confirmed gender dysphoria, capacity to make a fully informed decision, age ≥ 18 years or age of majority, and other significant medical or behavioral health concerns are well-controlled), in addition to the following:

• details regarding the type and duration of psychotherapy or evaluation the individual
• individual’s general identifying characteristics the initial and evolving gender, sexual and psychiatric diagnoses
• received the mental health professional’s rationale for hormone therapy or surgery
• the degree to which the individual has followed recommended medical management and likelihood of continued compliance
• whether or not the mental health professional is a part of a gender team

Psychiatric care may need to continue for several years after gender reassignment surgery, as major psychological adjustments may continue to be necessary. Other providers of care may include a family physician or internist, endocrinologist, urologist, plastic surgeon, general surgeon, and gynecologist. The overall success of the surgery is highly dependent on psychological adjustment and continued support. After diagnosis, the therapeutic approach is individualized but generally includes three elements: sex hormone therapy of the identified gender, real life experience in the desired role, and surgery to change the genitalia and other sex characteristics.

Medical Coverage Policy: 0266 Hormonal Therapy

For both adults and adolescents, hormonal treatment for gender dysphoria must be administered and monitored by a qualified healthcare practitioner as therapy requires ongoing medical management, including physical examination and laboratory studies to manage dosage, side effects, etc. Lifelong maintenance is usually required.

Adults:

Prior to and following gender reassignment surgery, individuals may undergo hormone replacement therapy. Biological males (i.e., assigned male at birth) are treated with estrogens and anti-androgens to increase breast size, redistribute body fat, soften skin, decrease body hair, and decrease testicular size and erections. Biological females (i.e., assigned female at birth) are treated with androgens such as testosterone to deepen voice, increase muscle and bone mass, decrease breast size, increase clitoris size, and increase facial and body hair. For some individuals hormone replacement therapy (HRT) may be effective in reducing the adverse psychologic impact of gender dysphoria. Hormone therapy is usually initiated upon referral from a qualified mental health professional or a health professional competent in behavioral health and gender dysphoria treatment specifically.

Adolescents:

Adolescence is generally defined as the time between puberty and reaching the age of majority (WPATH 8, 2022), an individual age 10 to 19 years (World Health Organization) or until reaching age 21 years (American Academy of Pediatrics [AAP]). For some adolescents the onset of puberty may worsen gender dysphoria. For these individuals puberty-suppressing hormones (e.g., GnRH analogues) may be provided to individuals who have reached at least Tanner stage 2 of sexual development (Hembree, et al., 2017; WPATH, 2022).

Consistent with adult hormone therapy, treatment of adolescents involves a multidisciplinary team

However, when treating an adolescent, a pediatric endocrinologist should be included as a part of the team. Pre-pubertal hormone suppression differs from hormone therapy used in adults and may not be without consequence; some pharmaceutical agents may cause negative physical side effects (e.g., height, bone growth).

Gender Reassignment Surgery

The term "gender reassignment surgery," also known as gender affirmation surgery, sexual reassignment surgery, or gender confirming surgery may be part of a treatment plan for gender dysphoria. The terms may be used to refer to either the reconstruction of male or female genitalia specifically, or the reshaping by any surgical procedure of a male body into a body with female appearance, or vice versa for an individual to function socially in the role to which they identify. Such procedures that tend to display outward appearance generally include facial procedures, chest reconstructive procedures as well as some genital reconstructive procedures (e.g., phalloplasty).

Performing gender reassignment surgery prior to age 18, or the legal age to give consent, is not recommended by most professional societies (American College of Obstetricians and Gynecology [ACOG], 2017; American Psychiatric Association (APA), 2012; Endocrine Society, 2017). Gender reassignment surgery is intended to be a permanent change (non-reversible), establishing congruency between an individual’s gender identity and physical appearance. Therefore, a careful and accurate diagnosis is essential for treatment and can be made only as part of a long-term diagnostic process involving a multidisciplinary specialty approach that includes an extensive case history; gynecological, endocrine, and urological examination; and a clinical psychiatric/psychological examination.

Individuals who choose to undergo gender reassignment surgery must be fully informed regarding treatment options with confirmation from the mental health professional that the individual is considered a candidate for surgical treatment.

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At least six months of continuous hormone therapy is often prescribed prior to irreversible genital surgery. Contraindications to hormonal therapy include but are not limited to hypercoagulability conditions, known coronary artery disease, liver disease, and venous thromboembolism.

Other Associated Surgical Procedures

Services Otherwise Medically Necessary: Age-appropriate gender-specific services that would otherwise be considered medically necessary remain medically necessary services for transgender individuals, as appropriate to their biological anatomy. Examples include (but are not limited to): for female individuals transitioning to male (e.g., who have not undergone a mastectomy) breast cancer screening; for male individuals transitioning to female but who have retained the prostate gland, cancer screening or treatment of a prostate condition.

Reversal of Gender Reassignment:

Gender reassignment surgery is considered an irreversible intervention. Although infrequent, surgery to reverse a partially or fully completed gender reassignment (reversal of surgery to revise secondary sex characteristics), may be necessary because of a complication (i.e., infection) or other medical condition necessitating surgical intervention.

Masculinization/Feminization Procedures:

Various other surgical procedures may be performed as part of gender reassignment surgery, for example masculinization or feminization procedures.

When performed as part of gender reassignment surgery some procedures are performed to assist with improving culturally appropriate male or female appearance characteristics and may be considered not medically necessary. Please refer to the applicable benefit plan document for terms, conditions, and limitations of coverage in addition to the applicable Cigna Medical Coverage Policy for conditions of coverage.

Professional Society/Organization

• American College of Obstetricians and Gynecologists (ACOG): ACOG published a Committee Opinion in 2017 for the care of transgender adolescents. Within this document regarding surgical management ACOG notes transgender male patients may undergo phalloplasty when one reaches the age of majority, and a transgender female patient may undergo vaginoplasty when one reaches the age of majority. In addition, the authors acknowledge the Endocrine Society guidelines (Hembree, et al., 2009) which state that an individual is at least age 18 years for genital reconstructive surgery (ACOG, 2017).
• American Psychiatric Association (APA): In 2012 the APA published a task force report on treatment of gender identity disorder. Within this document, regarding adolescents specifically, the authors state the evidence is inadequate to develop a guideline regarding the timing of sex reassignment surgery. However, the task force acknowledges the Endocrine Society guidelines (Hembree, et al., 2009) and that given the irreversible nature of surgery, for adolescents most clinicians advise waiting until the individual has attained the age of legal consent and a degree of independence (APA, 2012).
• WPATH Standards of Care: The World Professional Association for Transgender Health (WPATH) promotes standards of health care for individuals through the articulation of "Standards of Care for the Health of Transgender, and Gender Diverse People" (WPATH, 2022, Version 8). WPATH standards of care are based on scientific evidence and expert consensus and are commonly utilized as a clinical guide for individuals seeking treatment of gender disorders.
• Endocrine Society: Updated guidelines by the Endocrine Society for endocrine treatment of transsexual persons were published in 2017 (Hembree, et al., 2017). As part of this guideline, the endocrine society recommends that transsexual persons consider genital sex reassignment surgery only after both the physician responsible for endocrine transition therapy and the mental health professional find surgery advisable; that surgery be recommended only after completion of at least one year of consistent and compliant hormone treatment; and that the physician responsible for endocrine treatment medically clear the individual for sex reassignment surgery and collaborate with the surgeon regarding hormone use during and after surgery.

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