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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. Preferred products and authorization and coverage details are noted in the Drug Formulary.
    2. Progestin Replacement Therapy is generally covered. Preferred products and authorization and coverage details are noted in the Drug Formulary.
    3. Testosterone Therapy is generally covered. Preferred products and authorization 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, 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. Voice therapy.

Definitions

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 5 criteria for the diagnosis of gender identity disorder in adolescents and adults:

  1. Marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months' duration, as manifested by at least two of the following:
    1. A marked incongruence between one's experienced/expressed gender and primary, and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
    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 in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
    3. A strong desire for the primary and/or secondary sex characteristics of the other gender.
    4. A strong desire to be of the other gender (or some alternative gender different from one's assigned gender).
    5. A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender).
    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).
  2. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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, Gooren, L, Hannema, S., Meyer, W., Murad, M.H., Rosenthal, S….T’Sjoen, G..; 2017, Endocrine Society. Endocrine treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 102 (11) 3869-3903
  2. Hayes, Inc. Hayes Medical Technology Directory Report. Hormone Therapy for the Treatment of Gender Dysphoria. Landsdale, PA: Hayes, Inc.; May 2014 (reviewed April 2017)
  3. Tangpricha, V, Safer, J.,Transgender men: Evaluation and management . In: UpToDate, Synder, P, Matsumoto, A, (Ed), UpToDate, Waltham, MA. (Accessed on August 14, 2018)
  4. Tangpricha, V, Safer, J.,Transgender women: Evaluation and management . In: UpToDate, Synder, P, Matsumoto, A, (Ed), UpToDate, Waltham, MA. (Accessed on August 14, 2018.)
  5. 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.
  6. 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
  • 09/01/2018 - Effective date
Review date
  • 09/2018

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