Clinical Indications – When Gender Reassignment Surgery is covered

GRS may be considered medically reasonable and necessary when all the following candidate criteria are met and supporting provider documentation is submitted.

Candidate Criteria:
•The candidate is at least 18 years of age; and
•Has been diagnosed with GID, including meeting all of the following indications:

oThe desire to live and be accepted as a member of the opposite sex, typically accompanied by the desire to make the physical body as congruent as possible with the identified sex through surgery and hormone treatment; and
oThe desire for alternate gender identity has been present for at least 5 years; and
oThe GID is not a symptom of another mental disorder, hormonal aberration or chromosomal variation; and
oThe GID causes clinical distress or impairment in social, occupational, or other important areas of functioning.

•For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is:

oRecommended by a mental health professional and
oProvided under the supervision of a physician; and
othe supervising physician indicates that the patient has taken the hormones as directed.

•When the initial requested surgery is solely a mastectomy for candidates requesting female to male surgery, the treating physician may indicate that no hormonal treatment (as described above) is required prior to performance of the mastectomy. In this case, the 12 month requirement for hormonal treatment will be waived only when all other criteria contained in this policy are met.
•The candidate has completed a minimum of 12 months of successful continuous full time real-life experience in their new gender, with no returning to the original gender. This requirement must be demonstrated by living in their new gender while:

oMaintaining part- or full-time employment; or
oFunctioning as a student in an academic setting; or
oFunctioning in a community-based volunteer activity as applicable.

If the candidate does not meet the 12 month time frame criteria as noted above, then the treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet these criteria.
•Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual’s psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (e.g., if practicing within the same clinic) are required.
•The individual contemplating or undergoing GRS shall have documentation of regular therapy sessions with a qualified mental health professional for two (2) years prior and expectantly, two (2) years following GRS or therapy made available to the Medicare carrier upon request.

If the individual has significant medical or mental health issues present, they must be well controlled. If the individual is diagnosed with severe psychiatric disorders with impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder, paranoid state or equivalent debilitative disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated.

Failure to control and maintain a lifestyle devoid of psychotic behavior and ideations for a period of 24 months prior to planned surgical intervention renders the individual ineligible for surgical gender reassignment under the Medicare program due to the unacceptably high suicide risk and disastrous sequella seen in individuals psychologically unsuitable for this therapy.

* At least one of the professionals submitting a letter must have a doctoral degree (Ph.D., M.D., Ed.D, D.Sc., D.S.W., or Psy.D) and be capable of adequately evaluating co-morbid psychiatric conditions. One letter is sufficient if signed by two providers, one of whom has met the doctoral degree specifications, in addition to the specifications set forth above.

Primary Gender Reassignment Surgery (GRS-1) may consist of any combination of hysterectomy, salpingo-oophorectomy, mastectomy or orchiectomy, considered medically necessary when all of the above criteria are met.

Individuals having undergone (or in concert with) any combination of the above primary gender reassignment surgical procedures (GRS-1), may elect to pursue secondary genital reconstructive surgery (GRS-2) consisting of any combination of metoidioplasty, phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, reduction mammoplasty or mastectomy, or placement of testicular prostheses, Medical Necessity is established only when all criteria for Gender Reassignment Surgery are met.