Sunflower Health Plan Gender Affirming Procedures (PDF) Form

Services for gender affirmation most often include hormone treatment, counseling, psychotherapy, complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate, genital reconstruction, facial hair removal, and certain facial plastic reconstruction. Not every individual will require each intervention, so necessity needs to be considered on an individualized basis. This criteria outlines medical necessity criteria for gender-affirming medical and surgical treatment (GAMST) when such services are included under the member/enrollee’s benefit plan contract provisions. *Note: For procedures related to fertility preservation please see policy CP.MP.130 Fertility Preservation. Policy/Criteria I. It is the policy of Health Plans affiliated with Centene Corporation® that gender-affirming surgeries are considered medically necessary for members/enrollees when diagnosed with gender dysphoria or gender incongruence per section A. and when meeting the eligibility criteria in section B. Note: Intersex individuals are not subject to the criteria in this policy. A. Gender Dysphoria or Gender Incongruence Criteria 1. Marked and sustained incongruence between the member/enrollee’s experienced/expressed gender and assigned gender, as indicated by two or more of the following: a. Marked incongruence between the member/enrollee’s experienced/expressed gender and primary and/or secondary sex characteristics; b. 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; c. A strong desire for the primary and/or secondary sex characteristics of the other gender; d. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender); e. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender); f. 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); g. The condition is associated with impairment in social, occupational, or other important areas of functioning. B. Eligibility criteria, all of the following: Page 1 of 15 CLINICAL POLICY Gender-Affirming Procedures 1. Capacity to make a fully informed decision (including, but not limited to, awareness of the potential effects of treatment on fertility) and to consent for treatment; 2. If significant medical or mental health concerns present, they are reasonably well controlled; 3. Other possible causes of apparent gender dysphoria, gender incongruence, or gender diversity have been identified and excluded; 4. Minimum of one written statement with signature recommending gender-affirming medical and surgical treatment (GAMST) from a health care provider competent to independently assess and diagnose gender incongruence; 5. One of the following: a. For members ≥ 18 years, all of the following: i. Assessment for GAMST from a provider who meets both of the following: a) Has experience in or is qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity (e.g., mental health professional, general medical practitioner, nurse, or other qualified health care provider); b) Is licensed by their statutory body and hold, at a minimum, a master’s degree in a clinical field related to transgender health or equivalent further clinical training and be statutorily regulated; ii. The documented assessment for GAMST meets all of the following: a) Identifies any mental or physical health conditions that could negatively impact the outcome of GAMST, with risks and benefits discussed; b) Notes the member/enrollee’s capacity to understand the effect of GAMST on reproduction and includes a discussion of reproductive options with the member/enrollee prior to the initiation of GAMST; iii. Member/enrollee remains stable on their gender affirming hormonal treatment regime (which may include at least six months of hormone treatment or longer if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated). b. For members/enrollees < 18 years all of the following: i. Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment; ii. Has reached Tanner stage 2; iii. Member/enrollee has been informed of the reproductive effects of GAMST, including the potential loss of fertility and the available options to preserve fertility, and these have been discussed in the context of the adolescent’s stage of pubertal development; iv. Member/enrollee has completed a minimum of 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender-affirming procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment unless hormone therapy is either not desired or is medically contraindicated; v. Assessment for GAMST from a provider who meets both of the following: Page 2 of 15 CLINICAL POLICY Gender-Affirming Procedures a) Has experience in or is qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity (e.g., mental health professional, general medical practitioner, nurse, or other qualified health care provider); b) Is licensed by their statutory body and hold, at a minimum, a master’s degree in a clinical field related to transgender health or equivalent further clinical training and be statutorily regulated; C. Gender-affirming surgeries considered medically necessary when meeting above criteria and additional criteria as listed below for specific procedures: 1. For members/enrollees age < 18 years, any of the following: a. One of the following procedures is requested: i. Penectomy; ii. Urethroplasty; iii. Mammoplasty; iv. Mastectomy, and the member/enrollee has been assessed for risk factors associated with breast cancer; v. Clitoroplasty; vi. Vulvoplasty; vii. Labiaplasty; viii. Vaginectomy; ix. Vulvectomy; x. Scrotoplasty; xi. Testicular prosthesis; b. Twelve months of hormone therapy has been administered (unless hormone therapy is not desired or is medically contraindicated) and one of the following procedures has been requested: i. Breast augmentation, and the member/enrollee has been assessed for risk factors associated with breast cancer; ii. Phalloplasty; iii. Metoidioplasty; iv. Vaginoplasty; v. Gonadectomy (i.e., hysterectomy, orchiectomy); 2. For members/enrollees ≥ 18 years of age, any of the following: a. Penectomy; b. Urethroplasty; c. Mammoplasty; d. Mastectomy, and the member/enrollee has been assessed for risk factors associated with breast cancer; e. Clitoroplasty; f. Vulvoplasty; g. Labiaplasty; h. Vaginectomy; i. Vulvectomy; j. Scrotoplasty; k. Testicular prosthesis; Page 3 of 15 CLINICAL POLICY Gender-Affirming Procedures l. Breast augmentation, and the member/enrollee has been assessed for risk factors associated with breast cancer; m. Phalloplasty; n. Metoidioplasty; o. Vaginoplasty; p. Gonadectomy (i.e., hysterectomy, salpingo-oophorectomy, orchiectomy; at least six months of hormone therapy may be considered prior to procedure, as appropriate for the member/enrollee’s goals). II. It is the policy of Health Plans affiliated with Centene Corporation that gender affirming facial procedures will be considered for medical necessity on a case-by-case basis when meeting the following: A. Criteria has been met in section I.A. and I.B.; B. Requested procedure intends to correct existing facial appearance that demonstrates significant variation from standard appearance for the experienced gender. For members/enrollees <18 years, 12 months of hormone therapy is required prior to facial surgery as part of gender-affirming treatment unless hormone therapy is either not desired or medically contraindicated. Possible procedures include, but are not limited to, the following: 1. Blepharoplasty; 2. Face lift/mid-face lift/brow lift; 3. Facial implants and bone reconstruction; 4. Hair removal/electrolysis; 5. Drugs for hair loss or growth; 6. Hair transplantation or hairline advancement; 7. Prosthetic or filler substances to alter contour; 8. Rhinoplasty; 9. Thyroid chondroplasty; 10. Removal of redundant skin; 11. Upper lip shortening and lip augmentation; 12. Chondrolaryngoplasty; 13. Voice modification surgery, therapy, or lessons. III.It is the policy of Health Plans affiliated with Centene Corporation that revision procedures for affirming gender are medically necessary when the revision is required to address complications of a prior gender affirming procedure (wound dehiscence, fistula, chronic pain directly related to the surgery, etc.). IV. It is the policy of Health Plans affiliated with Centene Corporation that the following procedures, when used to improve the gender specific appearance of a member/enrollee undergoing gender affirmation are not medically necessary as they are considered cosmetic in nature (not an all-inclusive list): • Abdominoplasty • Liposuction • Skin resurfacing • Mastopexy Page 4 of 15 CLINICAL POLICY Gender-Affirming Procedures • Revision procedures for purposes other than correction of complications. V. It is the policy of Health Plans affiliated with Centene Corporation that detransition procedures by gender-related hormone intervention, surgical intervention, or both, will be considered for medical necessity on a case-by-case basis. Background Gender identity is a person’s deepest inner sense of being female or male, which for many is established by the age of two through three years. Gender nonconformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex.5 Gender dysphoria refers to the discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics).2,5 Per WPATH, the focus of gender dysphoria is not on the individual’s gender identity, but on any of the distress or discomfort related to being transgender and gender diverse (TGD).10 WPATH states that gender incongruence is considered a condition with a focus on the TGD person’s experienced identity and any need for gender-affirming treatment that arises from this identity.10 Treatment to assist people with gender dysphoria is available and can help to find the gender identity and role that is comfortable for them. Treatment is very individualized and may or may not involve gender-affirming surgery or body modification. Treatment options include changes in gender expression and role; hormone therapy to feminize or masculinize the body; surgery to change primary and/or secondary sex characteristics; and psychotherapy. Many people who receive treatment for gender dysphoria will find a gender role and expression that is comfortable for them, regardless of whether they differ from the sex assigned them at birth. The World Professional Association for Transgender Health (WPATH) is an international professional society dedicated to promoting the highest level of evidence-based principles for transgender and gender diverse (TGD) individuals. WPATH’s Standards of Care (SOC) are a series of flexible guidelines for clinical practice published by the society and are based on evidence and expert consensus.20 Version 8 of WPATH’s SOC were published in 2022, and these guidelines offer clinical guidance to health care professionals caring for TGD people and are intended to be adaptable to meet the diverse health care needs of this population. WPATH recommends that the assessment for gender-affirming medical and surgical treatment (GAMST) in individuals < 18 years old be completed by a provider who is licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution. The provider(s) working with gender diverse adolescents should additionally meet all of the following10: 1. Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum; 2. Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span; Page 5 of 15 CLINICAL POLICY Gender-Affirming Procedures 3. Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender diverse adolescents; 4. Continue engaging in professional development in all areas relevant to gender diverse children, adolescents, and families; 5. Complete a comprehensive biopsychosocial assessment of the adolescent member/enrollee presenting with gender identity-related concerns and seek medical/surgical transition-related care in a collaborative and supportive manner; 6. Maintain an ongoing relationship with the gender diverse and transgender adolescent member/enrollee and any relevant caregivers to support the adolescent in their decision- making throughout the duration of puberty suppression treatment, hormonal treatment, and gender- related surgery until the transition is made to adult care; 7. Involve parent(s)/guardian(s) in the GAMST assessment and treatment process, unless their involvement is determined to be harmful to the adolescent or not feasible; 8. Involve relevant disciplines, including mental health and medical professionals, to reach a decision about whether puberty suppression, hormone initiation, or gender-related surgery for gender diverse and transgender adolescents are appropriate and remain indicated throughout the course of treatment until the transition is made to adult care. WPATH recommends that the assessment for GAMST in adults ≥ 18 years of age be completed by a provider who is licensed by their statutory body and hold, at a minimum, a master’s degree in a clinical field related to transgender health or equivalent further clinical training and be statutorily regulated (e.g., mental health professional, general medical practitioner, nurse, or other qualified health care provider). The provider(s) working with gender diverse adults should additionally meet all of the following10: 1. Identify co-existing mental health or other psychosocial concerns, distinguishing these from gender dysphoria, incongruence, and diversity; 2. Assess capacity to consent for treatment (capacity to consent is required for GAMST assessment); 3. Have experience or is qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity and is able to liaise with professionals from different disciplines within the field of transgender health for consultation and referral, if required; 4. Identify and exclude other possible causes of apparent gender incongruence prior to the initiation of gender-affirming treatments; 5. Ensure any mental or physical health conditions that could negatively impact the outcome of GAMSTs are assessed, with risks and benefits discussed, before a decision is made regarding treatment; 6. Assess the member/enrollee’s capacity to understand the effect of GAMST on reproduction and discuss reproduction options with the member/enrollee prior to the initiation of GAMST; 7. Assess and discuss the role of social transition with the member/enrollee requesting GAMST. Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted Page 6 of 15 CLINICAL POLICY Gender-Affirming Procedures 2021, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT codes that may be considered part of gender-affirming surgery. This code list does not indicate if a procedure is or is not considered medically necessary. CPT® Codes 11950 through 11954 Subcutaneous injection of filling material (eg, collagen) 11960 11970 14000 14001 14040 14041 15100 15101 15120 15121 15200 15570 15574 15600 15620 15757 15758 15775 15776 Insertion of tissue expander(s) for other than breast, including subsequent expansion Replacement of tissue expander with permanent implant Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less Formation of direct or tubed pedicle, with or without transfer; trunk Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet Delay of flap or sectioning of flap (division and inset); at trunk Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet Free skin flap with microvascular anastomosis Free fascial flap with microvascular anastomosis Punch graft for hair transplant; 1 to 15 punch grafts Punch graft for hair transplant; more than 15 punch grafts Page 7 of 15 CLINICAL POLICY Gender-Affirming Procedures CPT® Codes 15780 through 15783 15786 15787 15788 15789 15792 15793 15820 through 15823 15824 15825 15826 15828 15829 15830 15832 through 15839 15876 through 15879 17380 19303 19316 19318 19325 19350 21120 21121 21122 21123 21125 21127 21208 21209 21210 21270 30400 Dermabrasion Abrasion; single lesion (eg, keratosis, scar) Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure) Chemical peel, facial; epidermal Chemical peel, facial; dermal Chemical peel, nonfacial; epidermal Chemical peel, nonfacial; dermal Blepharoplasty Rhytidectomy; forehead Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) Rhytidectomy; glabellar frown lines Rhytidectomy; cheek, chin, and neck Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy Excision, excessive skin and subcutaneous tissue (includes lipectomy) Suction assisted lipectomy Electrolysis epilation, each 30 minutes Mastectomy, simple, complete Mastopexy Breast reduction Breast augmentation with implant Nipple/areola reconstruction Genioplasty; augmentation (autograft, allograft, prosthetic material) Genioplasty; sliding osteotomy, single piece Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) Augmentation, mandibular body or angle; prosthetic material Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) Osteoplasty, facial bones; reduction Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) Malar augmentation, prosthetic material Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip Page 8 of 15 CLINICAL POLICY Gender-Affirming Procedures CPT® Codes 30410 30420 30430 30435 30450 31599 31899 53410 53415 53420 53425 53430 53460 54125 54400 54401 54405 54406 54408 54410 54411 54415 54416 54417 54520 54660 54690 55175 55180 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip Rhinoplasty, primary; including major septal repair Rhinoplasty, secondary; minor revision (small amount of nasal tip work) Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) Unlisted procedure, larynx Unlisted procedure, trachea, bronchi Urethroplasty, 1-stage reconstruction of male anterior urethra Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage Urethroplasty reconstruction female urethra Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type procedure) Amputation of penis; complete Insertion of penile prosthesis; non-inflatable (semi-rigid) Insertion of penile prosthesis; inflatable (self-contained) Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis Repair of component(s) of a multi-component, inflatable penile prosthesis Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis Removal and replacement of non-inflatable (semi-rigid) or inflatable (self- contained) penile prosthesis at the same operative session Removal and replacement of non-inflatable (semi-rigid) or inflatable (self- contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue Orchiectomy simple with or without testicular prosthesis, scrotal or inguinal approach Insertion testicular prosthesis (separate procedure) Laparoscopy, surgical; orchiectomy Scrotoplasty; simple Scrotoplasty; complicated Page 9 of 15 CLINICAL POLICY Gender-Affirming Procedures CPT® Codes 55970 55980 56625 56800 56805 56810 57106 57107 57110 57111 57291 57292 57295 57296 57335 57426 58150 58260 58262 58263 58267 58270 58275 58285 58290 58291 58292 58294 58541 58542 58543 58544 Intersex surgery; male to female Intersex surgery; female to male Vulvectomy simple; complete Plastic repair of introitus Clitoroplasty intersex state Perineoplasty, repair of perineum, nonobstetrical (separate procedure) Vaginectomy, partial removal of vaginal wall; Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) Vaginectomy complete removal vaginal wall Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) Construction artificial vagina; without graft Construction artificial vagina; with graft Revision (including removal) of prosthetic vaginal graft; vaginal approach Revision (including removal) of prosthetic vaginal graft; open abdominal approach Vaginoplasty intersex state Revision (including removal) of prosthetic vaginal graft, laparoscopic approach Total abdominal hysterectomy (corpus and cervix) with or without removal of tube(s), with or without removal of ovary(s) Vaginal hysterectomy, for uterus 250 g or less Vaginal hysterectomy uterus 250 g or less; with removal of tube(s) and/or ovary (s) Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele Vaginal hysterectomy, with total or partial vaginectomy Vaginal hysterectomy, radical (Schauta type operation) Vaginal hysterectomy, for uterus greater than 250 g Vaginal hysterectomy uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Page 10 of 15 CLINICAL POLICY Gender-Affirming Procedures CPT® Codes 58550 58552 58553 58554 58570 58571 58572 58573 58661 58720 58940 58999 64856 64892 64896 67900 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary (s) Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) Laparoscopy, surgical, with total hysterectomy for uterus greater than 250 g Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Laparoscopy surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) Oophorectomy, partial or total, unilateral or bilateral Unlisted procedure, female genital system (nonobstetrical) Suture of major peripheral nerve, arm or leg, except sciatic; including transposition Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; more than 4 cm length Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) Reviews, Revisions, and Approvals Policy developed; specialist reviewed Added clitoroplasty, vulvoplasty and labiaplasty to section III.A. References reviewed and updated. Codes reviewed and updated. Replaced term “gender reassignment” with “gender affirmation” throughout the policy and changed title to “Gender Affirming Procedures”. Added criteria for endometrial ablation as a medically necessary procedure for transmen. Added as not medically necessary brow lift and voice therapy/lessons. Codes reviewed (14040 corrected and 14001 and 15101 added, along with various description updates). Reviewed by specialist. Removed indication for endometrial ablation as it is included in CP.MP.106. Removed CPT code 19304 - code deleted 1/1/2020 Added statement that revision procedures are medically necessary when performed to correct procedure complications. Added revisions for other purposes to the cosmetic, not medically necessary list. Removed Revision Date 11/14 09/18 Approval Date 11/14 10/18 10/19 10/19 11/19 04/20 08/20 08/20 Page 11 of 15 CLINICAL POLICY Gender-Affirming Procedures Reviews, Revisions, and Approvals background statement that only some transgender, transsexual, and gender nonconforming people experience gender dysphoria. References reviewed and updated. Added characteristics of a mental health provider to II.F and II.G. Revised criteria in II.G to allow second referral letter from a qualified mental health provider, rather than limiting to psychologist or psychiatrist. References reviewed and updated. of CPT 11970, 19325 revised in 2021. CPT 19324, 58293 deleted in 2021. Replaced “member” with “member/enrollee.” Added 19318 to the list of CPT codes that may be considered part of gender affirming procedures. Annual Review. Changed “Last Review Date” to “Date of Last Revision” in the header. Added note before the criteria section stating that individuals with a disorder of sexual development (i.e. intersex) don’t need to meet all the same criteria for duration of gender dysphoria, age requirements and duration of prior treatment such as hormone therapy. Incorporated gender- neutral language to the eligibility and criteria section II. A. 1, E. and III. A. and B. In II.B., noted that informed consent includes awareness of treatment effects on fertility. Added the word “minimum” to degree requirement in criteria II.F. and G. In II.E, noted that the requirement of 12 months of hormone therapy before mastectomy in adolescents should be considered on a case-by-case basis. Added new criteria in section IV regarding facial procedures, and modified the not medically necessary procedures list in VI accordingly. Grammatical changes made to the background with no impact to the policy. “Date” changed to “Revision Date” in the revision log header. References reviewed and updated. Specialist reviewed. Criteria updated to incorporate WPATH Standards of Care version 8 (SOC-8). Noted that intersex individuals are not subject to this criteria I. Background updated to reflect updates in WPATH SOC-8. Reference list updated to replace WPATH SOC-7 to SOC-8. Reviewed by internal specialist and external specialist. Revision Date Approval Date 03/21 04/21 11/21 08/22 08/22 01/23 01/23