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 gender dysphoria diagnosis requires a marked incongruence between an individual's experienced/expressed gender and their assigned gender lasting for at least six months. This may cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

Gender affirmation surgery involves various reconstructive procedures performed to change primary and/or secondary sex characteristics in order 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)
• 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, some may require revision due to postoperative complications.

Coverage Determination

Any state mandates for gender affirmation surgery take precedence over this medical coverage policy.

Please refer to the member’s applicable pharmacy benefit to determine benefit availability and the terms and conditions of coverage for medication for the treatment of gender dysphoria.

Gender Affirmation Surgery

Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0518-020

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Services provided by a psychiatrist, psychologist or other behavioral health professionals are subject to the provisions of the applicable behavioral health benefit.

Gender Affirming Genital Surgery

Humana members may be eligible under the Plan for gonadectomy (eg, hysterectomy, orchiectomy, salpingo-oophorectomy) when ALL of the following criteria are met:

• 18 years of age or older; AND
• 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 ALL of the following:
  • Persistent, well-documented diagnosis of gender dysphoria according to the DSM-5 with clinical notes submitted; AND
  • 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
  • 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

Humana members may be eligible under the Plan for genital reconstructive surgery (eg, clitoroplasty, labiaplasty, metoidioplasty, penectomy, penile prosthesis, phalloplasty, scrotoplasty, testicular prosthesis placement, urethroplasty, vaginectomy, vaginoplasty, vulvectomy) when ALL of the following criteria are met:

• 18 years of age or older; AND
• 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 ALL of the following:
  • Persistent, well-documented diagnosis of gender dysphoria according to the DSM-5 with clinical notes submitted; AND
  • 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
  • 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

Humana members may be eligible under the Plan for permanent hair removal by electrolysis or laser when ALL of the following criteria 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)

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Gender Affirming Chest Surgery

Humana members may be eligible under the Plan for gender affirming chest surgery (eg, breast augmentation, breast reduction, mastectomy, nipple/areola reconstruction) when ALL of the following criteria are met:

• 18 years of age or older; AND
• 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 ALL of the following:
  • Persistent, well-documented diagnosis of gender dysphoria according to the DSM-5 with clinical notes submitted; AND
  • 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
  • 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

Humana members may be eligible under the Plan for revision of gender affirming procedures as a result of a surgical complication (eg, bleeding, hematoma, infection, injury to surrounding organs, mechanical complication [eg, fistula, malposition, strictures], remnant tissue, wound dehiscence).

Note: The criteria for gender affirming surgery are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Gender Affirmation Surgery

Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0518-020
Page: 6 of 30

Coverage Limitations

Humana members may NOT be eligible under the Plan for gender affirmation surgery for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for revision of gender affirming surgical procedures for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for reversal of gender affirming surgical procedures. This is considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for procurement, cryopreservation, storage and/or thawing of embryos, oocytes, sperm or reproductive tissue (eg, ovarian or testicular tissue). These are considered not medically necessary as defined in the member's individual certificate.

Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for any other procedures as part of gender affirmation surgery including, but may not be limited to, the following:

• Abdominoplasty
• Blepharoplasty**
• Body contouring
• Brow lift**
• Calf implants
• Cheek implants
• Chin implants
• Face lift

Gender Affirmation Surgery

Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0518-020
Page: 7 of 30

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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)
Voice therapy

These procedures are considered cosmetic. Please refer to the member’s individual certificate for the specific definition. **While these procedures may not be covered under this Medical Coverage Policy, Humana members may be eligible for them when criteria are met. For information regarding coverage determination/limitations, please refer to Blepharoplasty, Blepharoptosis Repair and Brow Lift, Erectile Dysfunction and Peyronie’s Disease Treatments, and Rhinoplasty/Septoplasty Medical Coverage Policies.

^Please refer to the Coverage Determination section for hair removal exception.

Background

Additional information about gender dysphoria may be found from the following websites:

• National Library of Medicine
• World Professional Association for Transgender Health

Gender Affirmation Surgery

Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0518-020
Page: 8 of 30

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.