Gender affirming medical and surgical treatment (GAMST) is part of the spectrum of care considered for transgender and gender diverse (TGD) individuals. Gender dysphoria refers to the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s sex assigned at birth. TGD individuals may have a gender that blends elements of both genders or doesn’t identify with any gender. The spectrum of gender identities experienced by TGD individuals may include identities such as non-binary, agender, gender fluid, and others. For this policy, the symptoms experienced by all TGD individuals will be referred to as gender dysphoria, recognizing that the spectrum of symptoms may vary from person to person. The therapeutic approach to gender dysphoria, are outlined by the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 from the World Professional Association for Transgender Health (WPATH). Treatment may involve multiple subspecialties, including but not limited to, primary care, speech and language therapy, endocrinology, dermatology, mental health, physical therapy, and surgical modalities. Gender affirming care interventions and/or GAMSTs consist of several interventions with the type and sequence of interventions differing from person to person. These include, but are not limited to, psychological and social interventions, social transition and/or treatment with hormones and/or surgery to change the genitalia and other sex characteristics.

I.   Criteria for All Procedures

Criteria are based on the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, from the World Professional Association for Transgender Health (WPATH).

Treatment of gender dysphoria may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following diagnostic criteria are met in addition to criteria for specific procedures listed in sections II, III, IV, and V:

• A comprehensive diagnostic assessment has been completed by a health care professional with the following qualifications:
  • Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution; and
  • Is experienced in the assessment and treatment of gender dysphoria, incongruence, and diversity; and
  • Has competence in the diagnosis of gender diverse identities and expressions, as well as in diagnosing possible comorbid disorders such as mood disorders, personality disorders, and substance related disorders; and
  • Has the ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria; and
  • Ability to assess capacity to consent for treatment; and
  • Participates in engagement with other health care professionals from different disciplines within the field of transgender health for consultation and referral, as needed.
• AND
• Based on the comprehensive evaluation, the individual meets the diagnostic criteria for gender dysphoria in adolescents and adults per the Diagnostic and Statistical Manual of Mental Health Disorders Fifth Edition, text revision (DSM 5-TR).
  • A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months' duration as manifested by at least two of the following:
    • A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics.
    • 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.
    • A strong desire for the primary and/or secondary sex characteristics of another gender. A strong desire to be another gender.
    • A strong desire to be treated as another gender. 
    • A strong conviction that one has the typical feelings and reactions of another gender.
  • AND
  • The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning;
• AND
• Demonstrates the emotional and cognitive maturity required to provide informed consent for the treatment; AND
• Other conditions (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been evaluated and addressed; AND
• The relationship of the member and healthcare provider spans at least 6 months duration; AND
• Documentation Requirements:
  • One consultation letter must be provided from a qualified healthcare professional (qualifications noted above). The letter must address ALL of the following:
    • The member's gender identifying characteristics; and
    • Results of the member's psychosocial assessment, including all diagnoses; and 
    • The duration of the health professional's relationship with the member including the type of evaluation and therapy or counseling to date; and
    • An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the member's request for surgery; and
    • A statement that the member has been informed that WPATH Standards of Care refer to breast/chest and genital surgical treatments as “irreversible,” and that reversal of breast/chest and genital surgical treatment are not eligible for coverage prior to providing informed consent for this surgery; and
    • A statement that informed consent has been obtained from the member. If the member is a minor informed consent from all legal guardians and assent from the minor has been obtained; and
    • A statement that the healthcare professional is available for coordination of care.
  • If surgical intervention is planned, documentation from the surgeon with recommendations for surgery.

Note: All formats of referral documentation including narrative and assessment templates are acceptable as long as criterion items are included.

II.    Breast Surgery

• Breast surgery (mastectomy or augmentation) for treatment of gender dysphoria may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:
  • Criteria in Section I are met; AND
  • Age is ONE of the following:
    • The member is 18 years of age; OR
    • Members < 18 years of age will be considered on a case-by-case basis with evidence of ALL of the following:
      • A multidisciplinary team approach is involved for eligible adolescents; and
      • Adolescent demonstrates emotional and cognitive maturity during the informed consent/assent to treatment process. 

III.  Genital Surgery

• Genital surgery for treatment of gender dysphoria may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:
  • One or more of the following procedures:
    • Electrolysis or laser hair removal to treat tissue donor sites for planned genital surgery;
    • Hysterectomy, salpingo-oophorectomy, orchiectomy, metoidioplasty or phalloplasty, urethroplasty, scrotoplasty, testicular prostheses, penectomy, vaginoplasty, labiaplasty, or clitoroplasty.
  • AND
  • Criteria in Section I are met; AND
  • Age 18 years or older; AND
  • The member has completed 12 continuous months of living in the identity that is congruent with their gender identity.

IV.  Reversal of Breast and Genital Surgery

• Breast and genital surgical procedures are considered irreversible, in accordance with WPATH Standards of Care, which refer to genital and breast/chest surgical treatments as “irreversible” and therefore advise that patients have sufficient time to absorb information fully before providing informed consent for these surgeries. Therefore, reversal of breast and genital surgical procedures are considered NOT MEDICALLY NECESSARY. 

V.   Additional Secondary Sex Characteristic Gender Affirming Medical and Surgical Procedures

• Non-surgical procedures for the treatment of gender dysphoria may be considered MEDICALLY NECESSARY AND APPROPRIATE to create and maintain gender specific characteristics as part of the overall desired GAMST treatment plan when ALL of the following criteria are met:
  • One or more of the following procedures:
    • Electrolysis or laser treatment for facial hair removal;
    • Voice therapy.
  • AND
  • Criteria in Section I are met;
• Surgical procedures for the treatment of gender dysphoria may be considered MEDICALLY NECESSARY AND APPROPRIATE to create and maintain gender specific/non-specific characteristics as part of the overall desired GAMST treatment plan when ALL of the following criteria are met:
  • One or more of the following procedures:
    • Voice modification surgery when voice/speech therapy has been ineffective;
    • Reduction thyroid chondroplasty or trachea shaving (reduction of Adam’s apple);
    • Facial surgery;
    • Face lift or liposuction, only when performed in conjunction with facial surgery.
  • AND
    • Criteria in Section I are met; AND
    • Age 18 years or older; AND
  • AND
• Documentation Requirements: 
  • For voice modification surgery, documentation from the treating speech therapy provider that speech therapy was tried and failed, and that voice modification surgery will provide further benefit.
• The following procedures do not have criteria specific to gender dysphoria, and criteria for coverage are addressed in separate medical policies:
  • Panniculectomy/Abdominoplasty;
  • Liposuction

• Revision of the initial gender affirming surgery may be considered MEDICALLY NECESSARY AND APPROPRIATE for ANY of the following: 
  • Surgical complication (e.g., hematoma, infection, bleeding, fistula, stricture, wound dehiscence); OR 
  • A functional impairment interfering with activities of daily living (e.g., complete vaginal stenosis, urethral stricture or fistula, inability to have penetrative intercourse, difficulty with voiding while standing); OR 
  • Removal and/or replacement of breast, penile, or testicular prostheses when due to complications (e.g., Baker IV contracture). 
• Revision of a previous gender affirming surgery because of dissatisfaction with appearance is considered COSMETIC.
  

• The following procedures are considered COSMETIC unless otherwise addressed by member contract benefits:
  • Gluteal augmentation;
  • Pectoral implants;
  • Calf implants.
    

Coverage

• Preventive health screening guidelines developed for the general population are appropriate for transgender and gender diverse persons for organ systems that are unlikely to be affected by hormone therapy. 
• Gender-specific preventive services are also necessary for transgender and gender diverse persons appropriate to their anatomy. Examples include the following: 
  • Routine Pap smears should be performed as recommended if cervical tissue is present 
  • If mastectomy is not performed, mammograms should be performed as recommended. 
  • Transgender and gender diverse persons treated with estrogen should follow the same screening guidelines for breast cancer as those for all women. 
  • Screening for prostate cancer should be performed as recommended for those persons who have retained their prostate. 
• Preservation of fertility is subject to the member’s contract benefits. This includes but is not limited to procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue.

Link to Commercial Pre-Authorization Form: https://www.bluecrossmn.com/sites/default/files/DAM/2021-12/BCBSMN-Pre-Auth-Request-fillable-X18509R07.pdf