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HealthPartners

Coverage criteria policies

Non-surgical treatment for gender dysphoria

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 documents will be used to determine your coverage.

Administrative Process

Non-surgical treatment is generally covered subject to the indications listed below and per your plan documents.

If a plan covers non-surgical treatment for gender dysphoria, the following non-surgical treatments are covered:

  1. Psychotherapy for gender dysphoria and associated co-morbid psychiatric diagnoses. Prior authorization is not required.
  2. Hormone Therapy is generally covered as follows.
    1. Estrogen Replacement Therapy is generally covered, without needing prior authorization. Preferred products and coverage details are noted in the Drug Formulary.
    2. Progestin Replacement Therapy is generally covered, without needing prior authorization. Preferred products and coverage details are noted in the Drug Formulary.
    3. Testosterone Therapy requires prior authorization due to multiple uses, but is covered for gender dysphoria without needing additional criteria. Preferred products and coverage details are noted in the Drug Formulary.
    4. Testosterone injections given in-clinic are covered, and do not require prior authorization.
    5. Gonadotropin releasing hormone analogs, such as leuprolide, to suppress pubertal hormones in adolescents are generally covered.
  3. Laboratory testing to monitor the safety of continuous hormone therapy. Prior authorization is not required.

The following non-surgical treatments are generally not covered for any indication, including, but not limited to:

  1. Non-surgical treatments that are not listed above.
  2. Drugs administered for cosmetic reasons.
  3. Hormone therapy not listed above.
  4. Voice therapy.

Definitions

Gender dysphoria: A disorder characterized by the following diagnostic criteria:

  1. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). This may be manifested in adults and children by a desire to live as or be treated as the other sex.
  2. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. In adults and adolescents, this may be manifested by a desire to get rid of primary and secondary sex characteristics.
  3. The disturbance is not concurrent with a physical intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia).
  4. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  5. The transsexual identity has been present persistently for at least two years.
  6. The disorder is not a symptom of another mental disorder or a chromosomal abnormality.

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.

Codes

Description

F64.1

Gender identity disorder in adolescence or adulthood

F64.2

Gender identity disorder of childhood

F64.8

Other gender identity disorders

F64.9

Gender identity disorder, unspecified

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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.

References

  1. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al; Endocrine Society. Endocrine treatment of transsexual persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132-3154.
  2. Hayes, Inc. Hayes Medical Technology Directory Report. Hormone Therapy for the Treatment of Gender Dysphoria. Landsdale, PA: Hayes, Inc.; May 2014 (reviewed May 2015).
  3. Wierckx, K., Van Caenegem, E., Schreiner, T., Haraldsen, I., Fisher, A., Toye, K., Kaufman, J. M. and T'Sjoen, G. (2014), Cross-Sex Hormone Therapy in Trans Persons Is Safe and Effective at Short-Time Follow-Up: Results from the European Network for the Investigation of Gender Incongruence. Journal of Sexual Medicine, 11: 1999–2011.
  4. World Professional Association for Transgender Health (WPATH SOC-7), Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People.

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Policy activity

  • 04/01/2016 - Date of origin
  • 04/01/2017 - Effective date
Review date
  • 04/2017

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