Humana Gender Affirmation Surgery - Medicare Advantage Form

Please refer to CMS website for the most current applicable National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/CMS Online Manual System/ Transmittals. Type Title ID Number Jurisdiction Medicare Administrative Contractors (MACs) Applicable States/Territories Gender Affirmation Surgery Page: 2 of 14 Internet- Only Manuals (IOMs) Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16 NCD LCA LCA Gender Dysphoria and Gender Reassignment Surgery Billing and Coding: Gender Reassignment Services for Gender Dysphoria Billing and Coding: Gender Reassignment Services for Gender Dysphoria § 120 General Exclusions from Coverage – Cosmetic Surgery 140.9 A53793 JJ - Palmetto GBA (Part A/B MAC) AL, GA, TN A53793 JM - Palmetto GBA (Part A/B MAC) NC, SC, VA, WV Description Gender dysphoria refers to discomfort or distress 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 6 months. This condition may cause clinically significant distress or impairment in social, occupational or other important areas of functioning.3 Gender affirmation surgery is an umbrella term for reconstructive procedures performed to change primary and/or secondary sex characteristics to align anatomy and physical appearance with an individual’s expressed gender identity. Gender affirming surgeries may include, but are not limited to, the following: • Breast augmentation (increase in breast size) • Breast reduction (decrease in breast size) • Clitoroplasty (creation of clitoris) • Hysterectomy (removal of uterus) • Labiaplasty (creation of labia) • Mastectomy (removal of breasts) • Metoidioplasty (creation of penis using clitoris) • Nipple/areola reconstruction (redefines features of natural breasts) • Orchiectomy (removal of testicles) • Penectomy (removal of penis) Gender Affirmation Surgery Page: 3 of 14 • Penile prosthesis (implant to allow for erection) • Phalloplasty (creation of penis) • Salpingo-oophorectomy (removal of fallopian tubes and ovaries) • Scrotoplasty (creation of scrotum) • Testicular prosthesis (artificial implant for testicles) • Urethroplasty (reconstruction of urethra) • Vaginectomy (removal of vagina) • Vaginoplasty (creation of vagina) • Vulvectomy (removal of vulva) Additional procedures to enhance femininity or masculinity may be requested. Please refer to the Coverage Limitations section for examples of these procedures. Gender affirmation surgeries are typically considered an irreversible type of intervention, depending on the type of procedures completed. However, an individual may require revision due to postoperative complications. Coverage Determination Humana follows the CMS requirement that only allows coverage and payment for services that are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by CMS In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria. Gender Affirming Genital Surgery Gonadectomy procedure(s) (eg, hysterectomy, orchiectomy, salpingo-oophorectomy) will be considered medically reasonable and necessary when all the following requirements5 are met: • Absence of a mental or physical impairment that would preclude a fully informed decision and/or consent; AND • One referral letter from a mental health professional stating that the individual has had, at minimum, 12 months of psychotherapy sessions attesting to the following: o Persistent, well-documented diagnosis of gender dysphoria according to the DSM-5 with clinical notes submitted; AND o Preoperative surgical clearance based on medical and psychological evaluation by a licensed healthcare professional to assess whether other coexisting conditions are regulated, maintained or managed without active exacerbations or concerns; AND Gender Affirmation Surgery Page: 4 of 14 o 12 continuous months* of living in a gender role that is congruent with their gender identity; AND • 12 continuous months of hormone therapy as appropriate to the individual’s gender goals, when medically appropriate and not contraindicated *The requirement for 12 continuous months of living in the desired gender role may or may not take place concurrently with the 12 continuous months of hormone therapy. Gender Affirming Genital Reconstructive Surgery Genital reconstructive surgery (eg, clitoroplasty, labiaplasty, metoidioplasty, penectomy, penile prosthesis, phalloplasty, scrotoplasty, testicular prosthesis placement, urethroplasty, vaginectomy, vaginoplasty, vulvectomy) will be considered medically reasonable and necessary when all the following requirements are met: • Absence of a mental or physical impairment that would preclude a fully informed decision and/or consent; AND • One referral letter from a mental health professional stating that the individual has had, at minimum, 12 months of psychotherapy sessions attesting to the following: o Persistent, well-documented diagnosis of gender dysphoria according to the DSM-5 with clinical notes submitted; AND o Preoperative surgical clearance based on medical and psychological evaluation by a licensed healthcare professional to assess whether other coexisting conditions are regulated, maintained or managed without active exacerbations or concerns; AND o 12 continuous months* of living in a gender role that is congruent with their gender identity; AND • 12 continuous months of hormone therapy as appropriate to the individual’s gender goals, when medically appropriate and not contraindicated Permanent hair removal by electrolysis or laser will be considered medically reasonable and necessary when all the following requirements are met: • Criteria for gender affirming genital reconstructive surgery has been met; AND • As preparation for genital reconstructive surgery which will require areas to be permanently without hair (eg, donor site tissue or tissue used for neopenis/neovagina) Gender Affirming Chest Surgery Gender Affirmation Surgery Page: 5 of 14 Gender affirming chest surgery (eg, breast augmentation, breast reduction, mastectomy, nipple/areola reconstruction) will be considered medically reasonable and necessary when all the following requirements are met: • Absence of a mental or physical impairment that would preclude a fully informed decision and/or consent; AND • One referral letter from a mental health professional stating that the individual has had, at minimum, 12 months of psychotherapy sessions attesting to the following: o Persistent, well-documented diagnosis of gender dysphoria according to the DSM-5 with clinical notes submitted; AND o Preoperative surgical clearance based on medical and psychological evaluation by a licensed healthcare professional to assess whether other coexisting conditions are regulated, maintained or managed without active exacerbations or concerns; AND o 12 continuous months* of living in a gender role that is congruent with their gender identity; AND • 12 continuous months of hormone therapy as appropriate to the individual’s gender goals, when medically appropriate and not contraindicated Revision of Gender Affirming Surgical Procedures Revision of gender affirming procedures will be considered medically reasonable and necessary when related to a surgical complication (eg, bleeding, hematoma, infection, injury to surrounding organs, mechanical complication [eg, fistula, malposition, strictures], remnant tissue, wound dehiscence). The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy. Coverage Limitations US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage The following services may not be considered a benefit (statutory exclusion): • Abdominoplasty • Blepharoplasty Gender Affirmation Surgery Page: 6 of 14 • Body contouring • Brow lift • Calf implants • Cheek implants • Chin implants • Face lift • Facial bone reduction (eg, osteoplasty) • Facial feminization/masculinization • Forehead contouring or lift • Gluteal implants • Hair removal** (eg, electrolysis, laser) • Hair transplantation • Injectable fillers (eg, collagen, fat or other biologic/synthetic material) • Jaw reduction (eg, jaw contouring) • Lip enhancement or reduction • Liposuction • Mastopexy • Neck tightening • Nose implants • Pectoral implants • Redundant skin removal • Rhinoplasty • Skin resurfacing (eg, chemical peel, dermabrasion) • Thyroid cartilage reduction (eg, chondroplasty) • Voice modification surgery (eg, cricothyroid approximation, laryngoplasty) These treatments and services fall within the Medicare program’s statutory exclusion that prohibits payment for items and services that have not been demonstrated to be reasonable and necessary for the diagnosis and treatment of illness or injury (§1862(a)(1) of the Act). Other procedures for gender affirmation surgery fall within the Medicare program’s statutory exclusion at 1862(a)(12), which prohibits payment. **Please refer to the Coverage Determination section for hair removal exception