Article - Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claimArticle TextGender Dysphoria (GD) is defined by the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, DSM-5 as a condition characterized by the "distress that may accompany the incongruence between ones experienced or expressed gender and ones assigned gender" also known as natal gender, which is the individuals sex determined at birth. Individuals with gender dysphoria experience confusion in their biological gender during their childhood, adolescence or adulthood. These individuals demonstrate clinically significant distress or impairment in social, occupational, or other important areas of functioning.GD is characterized by the desire to have the anatomy of the other sex, and the desire to be regarded by others as a member of the other sex. Individuals with GD may develop social isolation, emotional distress, poor self-image, depression and anxiety. The diagnosis of GD is not made if the individual has a congruent physical intersex condition such as congenital adrenal hyperplasia.Gender Reassignment TherapyGD cannot be treated by psychotherapy or through medical intervention alone. Integrated therapeutic approaches are used to treat GD, including psychological interventions and gender reassignment therapy. Gender reassignment therapy, either as male-to-female transsexuals (transwomen) or as female-to-male transsexuals (transmen), consists of medical and surgical treatment that changes primary or secondary sex characteristics.Initially, the individual may go through the real-life experience in the desired role, followed by cross-sex hormone therapy and gender reassignment surgery to change the genitalia and other sex characteristics. The difference between cross-sex hormone therapy and gender reassignment surgery is that the surgery is considered an irreversible physical intervention.Gender reassignment surgical procedures are not without risk for complications; therefore, individuals should undergo an extensive evaluation to explore psychological, family, and social issues prior to and post-surgery.Additionally, certain surgeries may improve gender- appropriate appearance but provide no significant improvement in physiological function. These surgeries are considered cosmetic and are non-covered.NON-SURGICAL TREATMENTInitiation of cross-sex hormone therapy may be provided after a psychosocial assessment has been conducted and informed consent has been obtained by a health professional.The criteria for cross sex hormone therapy are as follows:Persistent, well-documented gender dysphoria;Capacity to make a fully informed decision and to consent for treatment;Member must be at least 18 years of age;If significant medical or mental health concerns are present, they must be reasonably well controlled.The presence of co-existing mental health concerns does not necessarily preclude access to cross-sex hormones. These concerns should be managed prior to or concurrent with treatment of gender dysphoria.Cross-sex hormonal interventions are not without risk for complications, including irreversible physical changes. Medical records should indicate that an extensive evaluation was completed to explore psychological, family and social issues prior to and post treatment. Providers should also document that all information has been provided and understood regarding all aspects associated with the use of cross-sex hormone therapy, including both benefits and risks.READINESS FOR THE TREATMENT OF GENDER DYSPHORIAReadiness criteria for gender reassignment surgery includes the individual demonstrating progress in consolidating gender identity, and demonstrating progress in dealing with work, family, and interpersonal issues resulting in an improved state of mental health. In order to check the eligibility and readiness criteria for gender reassignment surgery, it is important for the individual to discuss the matter with a professional provider who is well-versed in the relevant medical and psychological aspects of GD. The mental health and medical professional providers responsible for the individual's treatment should work together in making a decision about the use of cross-sex hormones during the months before the gender reassignment surgery. Transsexual individuals should regularly participate in psychotherapy in order to have smooth transitions and adjustments to the new social and physical outcomes.TRANS-SPECIFIC CANCER SCREENINGSProfessional organizations such as the American Cancer Society, American College of Obstetricians and Gynecologists and the US Preventive Services Task Force provide recommended cancer screening guidelines to facilitate clinical decision-making by professional providers. Some cancer screening protocols are sex/gender specific based on assumptions about the genitalia for a particular gender. There is little data on cancer risk specifically in transsexual individuals.There is difficulty in recommending sex/gender specific screenings (e.g., breast, cervix, ovaries, penis, prostate, testicles and uterus) for transsexual individuals because of their physiologic changes. For example, transmen who have not undergone a mastectomy have the same risks for breast cancer as natal women. In transwomen, the prostate typically is not removed as part of genital surgery, so individuals who do not take feminizing hormones may be at the same risk for prostate cancer as natal men. Therefore, cancer screenings (e.g., mammograms, prostate screenings) may be indicated based on the individual's original gender.Gender specific screenings may be medically necessary for transgender persons appropriate to their anatomy. Examples include:Breast cancer screening may be medically necessary for transmen who have not undergone a mastectomy.Prostate cancer screening may be medically necessary for transwomen who have retained their prostate.Claims for gender reassignment surgery will be reviewed on a case-by-case basis. Surgical treatment of gender reassignment surgery for gender dysphoria may be eligible when medical necessity and documentation requirements outlined within this article are met.Surgical treatment for gender dysphoria may be considered medically necessary whenALLof the following criteria are met:The individual is at least 18 years of age.A gender reassignment treatment plan is created specific to an individual beneficiaryThe individual has a documented Diagnostic and Statistical Manual of Mental Disorders -Fifth Edition, DSM-5  diagnosis of GD:A.A marked incongruence between ones 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 ones experienced/expressed gender and primary and/or secondary sex characteristics.A strong desire to be rid of ones primary and/or secondary sex characteristics because of a marked incongruence with ones experienced/expressed gender.A strong desire for the primary and/or secondary sex characteristics of the other gender.A strong desire to be of the other gender (or some alternative gender different from ones assigned gender).A strong desire to be treated as the other gender (or some alternative gender different from ones assigned gender).A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from ones assigned gender).B.The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning.One letter from a mental health professional that the patient has had, at minimum, twelve months of psychotherapy therapy sessions attesting to all of the following clinical criteria:That any co-morbid psychiatric or other medical conditions are stable and that the individual is prepared to undergo surgery.That the patient has had persistent and chronic gender dysphoria.That the patient has completed twelve months of continuous, full-time, real-life experience (i.e., the act of fully adopting a new or evolving gender role or gender presentation in everyday life) in the desired gender.The individual, if required by the mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider.Unless medically contraindicated (or the individual is otherwise unable to take cross-sex hormones), there is documentation that the individual has participated in twelve consecutive months of cross-sex hormone therapy of the desired gender continuously and responsibly (e.g., screenings and follow-ups with the professional provider).The individual has knowledge of all practical aspects (e.g., required lengths of hospitalizations, likely complications, and post-surgical rehabilitation) of the gender reassignment surgery.SURGICAL TREATMENTS FOR GENDER REASSIGNMENTWhen all of the above criteria are met for gender reassignment surgery, the following genital surgeries may be considered for transwomen (male to female):Orchiectomy - removal of testiclesPenectomy - removal of penisVaginoplasty - creation of vaginaClitoroplasty - creation of clitorisLabiaplasty - creation of labiaMammaplasty - breast augmentationProstatectomy -removal of prostateUrethroplasty - creation of urethraWhen all of the above criteria are met for gender reassignment surgery, the following genital/breast surgeries may be considered for transmen (female to male):Breast reconstruction (e.g., mastectomy) - removal of breastHysterectomy - removal of uterusSalpingo-oophorectomy - removal of fallopian tubes and ovariesVaginectomy - removal of vaginaVulvectomy - removal of vulvaMetoidioplasty - creation of micro-penis, using clitorisPhalloplasty - creation of penis, with or without urethraUrethroplasty - creation of urethra within the penisScrotoplasty - creation of scrotumTesticular prostheses - implantation of artificial testesServices or procedures may not be covered when the criteria and documentation requirements outlined within this article are not met.The determination of whether to cover gender reassignment surgery and related care for a particular individual is based on whether the item or service is reasonable and necessary to treat the beneficiarys medical condition after considering the individuals specific circumstances. These decisions are made after the individual has obtained the medical service and a claim has been submitted by the Medicare provider.The individual's medical record must be submitted along with the claim and support the services billed. These medical records may include but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.When reporting procedure code 55970 (Intersex surgery; male to female), the following staged procedures to remove portions of the male genitalia and form female external genitals are included:The penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure.The urethral opening is moved to a position similar to that of a female.A vagina is made by dissecting and opening the perineum. This opening is lined using pedicle or split- thickness grafts.Labia are created out of skin from the scrotum and adjacent tissue.A stent or obturator is usually left in place in the newly created vagina for three weeks or longer.When reporting CPTcode 55980 (Intersex surgery; female to male), the following staged procedures to form a penis and scrotum using pedicle flap grafts and free skin grafts are included:Portions of the clitoris are used, as well as the adjacent skin.Prostheses are often placed in the penis to create a sexually functional organ.Prosthetic testicles are implanted in the scrotum.The vagina is closed or removed.