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Gender reassignment surgery

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

Prior authorization is required for gender reassignment surgery.

Prior authorization is not required for hormonal reassignment.

Gender reassignment surgery is generally covered subject to the indications listed below and per your plan documents. HealthPartners follows the World Professional Association for Transgender Health (WPATH SOC-7), guidelines for primary sex characteristic gender reassignment surgery.

Indications that are covered

  1. All of the following criteria must be met prior to mastectomy for female to male members:
    1. The member must:
      1. Have persistent, well documented gender dysphoria;
      2. Be at least 18 years old, the legal age of majority in Minnesota; and
      3. Have the capacity to make a fully informed decision and to consent for treatment; and
      4. Have one referral from a qualified mental health professional that addresses all 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 that informed consent has been obtained from the patient; and
        6. A statement that the mental health professional is available for coordination of care.
    2. If significant medical or mental health concerns are present, documentation must support that they are reasonably well controlled.

      Please note: Hormone therapy is not a prerequisite to mastectomy.

  2. All of the following criteria must be met prior to hysterectomy and oophrectomy in female to male members and orchiectomy for male to female members:
    1. The member must:
      1. Have persistent, well documented gender dysphoria.
      2. Be at least 18 years old, the legal age of majority in Minnesota; and
      3. Have the capacity to make a fully informed decision and to consent for treatment; and
      4. Have two referrals from two separate qualified mental health professionals. One therapist may be in a purely evaluative role, and one must address all of the following:
        1. The member’s general identifying characteristics; and
        2. 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
        3. 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
        4. A statement that the mental health professional is available for coordination of care.
    2. If significant medical or mental health concerns are present, documentation must support that they are reasonably well controlled; and
    3. Twelve months of continuous hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones).
  3. All of the following criteria must be met prior to genital reconstructive surgery (i.e., vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular prosthesis and erectile prosthesis in female to male; penectomy, vaginoplasty, labiaplasty, and clitoroplasty in male to female).
    1. The member must:
      1. Have persistent, well documented gender dysphoria.
      2. Be at least 18 years old, the legal age of majority in Minnesota; and
      3. Have the capacity to make a fully informed decision and to consent for treatment; and
      4. Have two referrals from two separate qualified mental health professionals. One therapist may be in a purely evaluative role, and one must address all 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 that informed consent has been obtained from the patient; and
        6. A statement that the mental health professional is available for coordination of care.
    2. If significant medical or mental health concerns are present, documentation must support that they are reasonably well controlled; and
    3. Twelve months of continuous hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones); and
    4. The member must have completed 12 continuous months of living in a gender role that is congruent with their gender identity.

      Please note: Although not an explicit criterion, it is recommended that members undergoing these procedures also have regular visits with a mental health or other medical professional.

Indications that are not covered

Other surgeries done to enhance the physical appearance or to more closely meet secondary sex characteristics of the reassigned gender including but not limited to thyroid cartilage shaving, plastic surgery on the eyes, lips or chin, face lifts, voice modification surgery, breast or chest augmentation, nose modification, skin resurfacing, and any other surgeries deemed cosmetic are not covered. Please see related content at right for link to cosmetic policy.

Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). (WPATH SOC-7 2011).

DSM IV-TR criteria for the diagnosis of gender identity disorder in adolescents and adults:

  1. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In adolescents and adults, the disturbance in manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex; and
  2. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g. request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex; and
  3. The disturbance is not concurrent with a physical intersex condition; and
  4. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Gender reassignment refers to the hormonal and surgical reassignment of gender dysphoric persons.

Gender reassignment surgery may involve any of a number of procedures including mastectomy, reduction mammoplasty, orchidectomy, penectomy, urethroplasty, vaginoplasty, labiaplasty, clitoroplasty, hysterectomy, salpingectomy, oophrectomy,  vaginectomy and phalloplasty or metoidioplasty, scrotoplasty, and placement of a testicular prosthesis and erectile prosthesis.

Hormonal gender reassignment refers to the administration of androgens (male hormones) to genetic females and estrogens and/or progesterones (female hormones) to genetic males for the purpose of effecting somatic changes (softening of skin, hair growth, breast development etc.) in order to more closely approximate the physical appearance of the other gender.

Primary sex characteristics refer to the genetically determined sex characteristics related to reproduction. The primary sex characteristics are the genital organs and their related hormones.

Secondary sex characteristics refer to various genetically transmitted physical or behavioral characteristics that appear in humans at puberty and differentiate between the sexes without having a direct reproductive function.

Qualified Mental Health Professional (from the WPATH SOC-7)

  1. Master’s degree or equivalent in a clinical behavioral science field granted by an institution accredited by the appropriate national accrediting board. The professional should also have documented credentials from the relevant licensing board or equivalent; and
  2. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Disease for diagnostic purposes; and
  3. Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria;
  4. Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria; and
  5. Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

55970 - Intersex surgery, male to female
55980 - Intersex surgery, female to male

Portions of this policy were derived from the World Professional Association for Transgender Health (WPATH SOC-7), Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People.

Please see related content at right for link to WPATH Standards of Care.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 7/01/1997 - Date of origin
  • 7/01/1997 - Effective date
Reviews & revisions
  • 4/2014
Policy number
  • G008-05

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