Blue Cross Blue Shield Minnesota Growth Hormone Criteria

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Gender Affirming Procedures for Gender Dysphoria

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This policy version was replaced on May 31, 2021. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management , read and accept the Blue Cross Medical Policy Statement, then select "Blue Cross and Blue Shield of Minnesota Medical Policies." This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Gender dysphoria refers to the distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender. The therapeutic approach to gender dysphoria, as outlined by the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, Version 7 from the World Professional Association for Transgender Health (WPATH), may consist of several interventions with the type and sequence of interventions differing from person to person. These include psychological and social interventions, continual experience living in the identity-congruent gender role, treatment with hormones and surgery to change the genitalia and other sex characteristics to that of the identity-congruent gender.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position

Coverage is subject to the specific terms of the member's benefit plan.

I.Criteria for All Procedures

Criteria are based on the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, from the World Professional Association for Transgender Health (WPATH), 7th edition.

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

• A comprehensive diagnostic evaluation has been completed by a psychiatrist, a clinical psychologist, or other licensed mental health professional who
  • Is experienced in the evaluation and treatment of gender dysphoria; and
  • Has competence in the diagnosis of gender nonconforming identities and expressions, as well as in diagnosing possible comorbid disorders such as psychotic 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
  • Meets the Minnesota Department of Human Services qualifications for a mental health professional, as set forth in Minn.Stat.245.4871, subds. 26 and 27 (2017) and Minn.Stat.245.462, subds. 17 and 18. Providers outside Minnesota must be appropriately licensed according to applicable state law; 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 (DSM 5).
  • 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:
    1. A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics.
    2. 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.
    3. A strong desire for the primary and/or secondary sex characteristics of the other gender.
    4. A strong desire to be the other gender (or some alternative gender different from one's assigned gender).
    5. A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender).
    6. 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). AND
  • The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning;
  • AND
• The member is at least 18 years of age (legal age of majority in Minnesota). (Requests for breast surgery for a member younger than 18 years of age will be reviewed by medical director); AND
• Capacity to make a fully informed decision and to give consent to treatment; AND
• If significant medical or mental health concerns are present, they must be reasonably well-controlled as confirmed by a qualified mental health professional (as defined above).
  

II.Breast Surgery

• Mastectomy and creation of a male chest in female-to-male members may be considered MEDICALLY NECESSARY AND APPROPRIATE when the criteria in section I are met.
  • NOTE:  Hormone therapy is not a prerequisite for mastectomy for female-to-male members. The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People Version 7 from the WPATH state the following:  "Chest surgery in FtM (female-to-male) patients could be carried out (before age of majority) preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent's specific clinical situation and goals for gender identiy expression."
• Breast augmentation (e.g. implants/lipofilling) may be considered MEDICALLY NECESSARY AND APPROPRIATEin male-to-female members when criteria in section I are met.
  • NOTE:  Hormone therapy is not a prerequisite for breast augmentation for male-to-female members. The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People Version 7 from the WPATH state the following:  "Although not an explicit criterion, it is recommended that MtF (male-to-female) patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results."
• Documentation Requirements
  • One letter of recommendation must be provided to a health plan representative from a qualified mental health professional (as defined in section I). The letter must addressALL of the following:
    1. The member's general identifying characteristics; and
    2. Results of the member's psychosocial assessment, including any diagnoses; and
    3. The duration of the mental health professional's relationship with the member including the type of evaluation and therapy or counseling to date; and
    4. 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
    5. A statement about the fact that informed consent has been obtained from the patient; and
    6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.
  • The health plan and the physician responsible for breast removal or augmentation must receive this letter and recommendations for surgery and the surgical treatment must be authorized by the health plan prior to its occurrence. If the providers are working within a multidisciplinary specialty team, the letters may be sent only to the health plan with documentation of the information in the member's chart.

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III.Genital Surgery

• Electrolysis or laser hair removal to treat tissue donor sites for planned genital surgery may be considered MEDICALLY NECESSARY AND APPROPRIATE when criteria in section I are met.
• Hysterectomy and salpingo-oophorectomy in female-to-male members and orchiectomy in male-to-female members may be considered MEDICALLY NECESSARY AND APPROPRIATE when the criteria in section I are met AND
  • The member has completed 12 continuous months of hormonal therapy as appropriate to the member's gender goals, unless hormones are not clinically indicated or are medically contraindicated for the individual.
• Metoidioplasty or phalloplasty, urethroplasty, scrotoplasty, and testicular prostheses in female-to-male members and penectomy, vaginoplasty, labiaplasty, and clitoroplasty in male-to-female members may be considered MEDICALLY NECESSARY AND APPROPRIATE when criteria in section I are met AND
  • The member has completed 12 continuous months of hormonal therapy as appropriate to the member's gender goals, unless hormones are not clinically indicated or are medically contraindicated for the individual; and
  • The member has completed 12 continuous months of living in a gender role that is congruent with their gender identity.
• Documentation Requirements
  • Two letters of recommendation from qualified mental health professionals (as defined in section I) have been obtained; one must be from a mental health professional who has had only an evaluative role with the patient.
  • Both letters must address ALL of the following:
    • The member's general identifying characteristics; and
    • Results of the member's psychosocial assessment, including any diagnoses; and
    • The duration of the mental 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 about the fact that informed consent has been obtained from the patient; and
    • A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.
  • These letters must be presented to the health plan and to the surgeon prior to genital surgery. If the providers are working within a multidisciplinary specialty team, the letters may be sent only to the health plan with documentation of the information in the patient's chart.

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IV.Reversal of Breast and Genital Surgery

• Breast and genital surgical procedures are considered irreversible, in accordance with WPATHStandards 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.

V.Secondary Sexual Characteristic (Masculinizing or Feminizing) Gender Reassignment Procedures

• The following procedures for the treatment of gender dysphoria may be considered MEDICALLY NECESSARY AND APPROPRIATE to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment treatment plan when criteria in section I are met:
  • Electrolysis or laser treatment for facial hair removal;
  • Voice therapy;
  • Voice modification surgery when voice/speech therapy has been ineffective;
  • Reduction thyroid chondroplasty or trachea shaving (reduction of Adam's apple);
• Documentation Requirements:
  
  • One letter of recommendation from a qualified mental health professional (as defined in section I) has been obtained and includes ALL of the following:
    
    • The member's general identifying characteristics; and
    • Results of the member's psychosocial assessment, including any diagnoses; and
    • The duration of the mental 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 about the fact that informed consent has been obtained from the patient; and
    • A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.
  • The letter must be presented to the health plan and to the surgeon prior to surgery. If the providers are working within a multidisciplinary specialty team, the letters may be sent only to the health plan with documentation of the information in the patient's chart.
  • 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.

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• The following procedures and criteria for coverage are addressed in separate medical policies:
  • Rhinoplasty (see policy IV-73;
  • Panniculectomy/Abdominoplasty (see policy IV-24);
  • Blepharoplasty (see policy IV-17).
    

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• The following procedures are considered COSMETIC unless otherwise addressed by member contract benefits:
  • Neck lift;
  • Face lift;
  • Facial bone osteoplasty for augmentation or reduction, including prosthetic material;
  • Gluteal augmentation;
  • Pectoral implants;
  • Calf implants.
    

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Coverage

• Preventive health screening guidelines developed for the general population are appropriate for transgender persons for organ systems that are unlikely to be affected by feminizing or masculinizing hormone therapy.
• Gender-specific preventive services are also necessary for transgender persons appropriate to their anatomy. Examples include the following:
  • Routine Pap smears should be performed as recommended if cervical tissue is present in female-to-male transgender persons.
  • If mastectomy is not performed, mammograms should be performed as recommended.
  • Male-to-female transgender 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.

Documentation Submission:

Link to Commercial Pre-Authorization Form: https://www.bluecrossmn.com/sites/default/files/DAM/2019-10/X18509R07_Pre-Authorization%20Request%20Form.pdf

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No additional statements.

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Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies.

Medicaid products and some self-insured plans may have additional policies and prior authorization requirements. As applicable, review the provisions relating to a specific coverage determination, including exclusions and limitations. Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

For Medicare NCD and/or Medicare LCD, please consult CMS or National Government Services websites.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and /or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only, and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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Source: https://securecms.bluecrossmnonline.com/content/medpolicy/en/minnesota/core/all/policies/Surgery/IV-123/IV-123-007.html

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