Gender Reassignment Surgery
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY
Gender Reassignment Surgery
Gender Identity Disorder (GID) is the formal diagnosis used to describe persons who experience significant gender dysphoria (discontent with their biological sex and/or birth gender). Although it is a psychiatric classification, GID is not medically classified as a mental illness.
In the U.S., the American Psychiatric Association (APA) permits a diagnosis of gender dysphoria if the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (DSM-5) are met. The criteria are:
A.A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six month’s duration, as manifested by at least two of the following:
1.A marked incongruence between one’s experienced/expressed gender and primary and/or sex characteristics; OR
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; OR
3.A strong desire for the primary and/or secondary sex characteristics of the other gender; OR
4.A strong desire to be of the other gender or some alternative gender different from one’s assigned gender; OR
5.A strong desire to be treated as the other gender or some alternative gender different from one’s assigned gender; OR
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
B.The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Gender reassignment surgery (GRS) is one treatment option for extreme cases of gender dysphoria or GID, a condition in which a person feels a strong and persistent identification with the opposite gender accompanied with a severe sense of discomfort in his or her own gender. People with gender dysphoria often report a feeling of being born the wrong sex. GRS is not a single procedure, but part of a complex process involving multiple medical, psychiatric, and surgical specialists working in conjunction with each other and the individual to achieve successful psychological, behavioral, functional and medical outcomes. Before undertaking gender reassignment surgery, candidates need to undergo important medical and psychological evaluations, begin medical therapies and behavioral trials to confirm that surgery is the appropriate treatment choice.
Prior to March 27, 2014, GRS was specifically excluded from coverage and reimbursement by The Center for Medicare and Medicaid Services. After May 30, 2014 procedures for GRS may be covered and reimbursable by Medicare when specific criteria outlined below are present and documented in the patient record.
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY
Gender Reassignment Surgery
Gender Identity Disorder (GID) is the formal diagnosis used to describe persons who experience significant gender dysphoria (discontent with their biological sex and/or birth gender). Although it is a psychiatric classification, GID is not medically classified as a mental illness.
In the U.S., the American Psychiatric Association (APA) permits a diagnosis of gender dysphoria if the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (DSM-5) are met. The criteria are:
A.A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six month’s duration, as manifested by at least two of the following:
1.A marked incongruence between one’s experienced/expressed gender and primary and/or sex characteristics; OR
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; OR
3.A strong desire for the primary and/or secondary sex characteristics of the other gender; OR
4.A strong desire to be of the other gender or some alternative gender different from one’s assigned gender; OR
5.A strong desire to be treated as the other gender or some alternative gender different from one’s assigned gender; OR
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
B.The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Gender reassignment surgery (GRS) is one treatment option for extreme cases of gender dysphoria or GID, a condition in which a person feels a strong and persistent identification with the opposite gender accompanied with a severe sense of discomfort in his or her own gender. People with gender dysphoria often report a feeling of being born the wrong sex. GRS is not a single procedure, but part of a complex process involving multiple medical, psychiatric, and surgical specialists working in conjunction with each other and the individual to achieve successful psychological, behavioral, functional and medical outcomes. Before undertaking gender reassignment surgery, candidates need to undergo important medical and psychological evaluations, begin medical therapies and behavioral trials to confirm that surgery is the appropriate treatment choice.
Prior to March 27, 2014, GRS was specifically excluded from coverage and reimbursement by The Center for Medicare and Medicaid Services. After May 30, 2014 procedures for GRS may be covered and reimbursable by Medicare when specific criteria outlined below are present and documented in the patient record.