Gender-Affirming Surgery

Revised: September 8, 2023

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Authorization Requirements

· Billing

Overview

Gender-Affirming surgery is considered medically necessary when a person has been diagnosed as having gender dysphoria and meets the established criteria. Treatment for gender dysphoria does not consist of a single procedure, but is part of a process involving multiple medical and surgical methods.

Eligible Providers

Physicians enrolled with Minnesota Health Care Programs (MHCP) may provide and bill MHCP for covered services.

Eligible Members

All members enrolled with MHCP may be eligible for covered services. Member must be 18 years of age or older to be eligible for phalloplasty.

Covered Services

MHCP covers the following services when medically necessary:

· Hysterectomy and salpingo-oophorectomy

· Vaginectomy (including colpectomy, metoidioplasty, phalloplasty, urethoplasty, urethromeatoplasty

· Mastectomy, breast reduction, chest reconstruction

· Penile prosthesis (noninflatable or inflatable)

· Orchiectomy

· Vaginoplasty (including colovaginoplasty, penectomy, labiaplasty, clitoroplasty, vulvoplasty, penile skin inversion, repair of introittus, construction of vagina with graft, coloproctostomy)

· Voice therapy

· Breast augmentation surgery for male-to-female GAS is covered upon completion of 6 months of hormone therapy (12 months for adolescents) unless hormone therapy is medically contraindicated or not desired.

· Scrotoplasty, testicular expanders, and testicular prostheses for female-to-male gender-affirming surgery

· Facial surgery may be considered for coverage on a case-by-case basis. Factors that may be considered in the case-by-case analysis include:

· How each requested procedure has a direct link to alleviating the documented symptoms of the gender dysphoria.

· Documentation showing that no other physical or behavioral health condition could be causing the distress that the facial surgery attempts to address.

· Explanation of how the symptoms will be alleviated through each requested procedure and how improvement will be measured and monitored.

· Electrolysis or laser hair preoperatively is covered and hair removal from the face, body, and genital areas for gender affirmation will be reviewed for medical necessity on a case-by-case basis that may include:

· Physician recommends hair removal prior to genital reconstruction for the treatment of gender dysphoria.

· Documentation explaining excessive hair growth and a letter from the clinician performing hair removal that supports the medical necessity of hair removal as it relates to gender dysphoria treatment.

· Voice modification surgery is covered on a case-by-case basis when medically necessary. Provider must document medical necessity. An example is by recommendation of a voice therapist because voice therapy has had an inadequate reduction in vocal dysphoria, existing vocal presentation significantly varies from the normal for the gender, and vocal therapy has been exhausted.

Hormone therapy is not a pre-requisite for covered services unless specified within this document

Noncovered Services

The following procedures are considered cosmetic and not medically necessary; therefore, these services are excluded from MHCP coverage:

· Abdominoplasty

· Blepharoplasty

· Calf implants

· Collagen injections

· Gluteal augmentation

· Hair transplantation

· Laryngoplasty

· Lipofilling or collagen injections

· Liposuction

· Mastopexy

· Neck tightening

· Pectoral implants

· Removal of redundant skin

· Skin resurfacing (dermabrasion, chemical peels)

· Trachea shave or thyroid cartilage reduction (chondroplasty)

Authorization Requirements

All gender-affirming surgery requires authorization. The member must meet the following criteria for the requested services before DHS can authorize coverage of gender-affirming surgery:

· Member must meet diagnostic criteria of gender incongruence (inconsistent).

· Provider has submitted documentation supporting that the member has experienced marked and sustained gender dysphoria over time.

· The member must demonstrate the emotional and cognitive maturity required to provide informed consent and approval for the treatment.

· Provider has submitted written referrals from clinicians qualified in the behavioral aspects of gender dysphoria. The referral letters must meet the following requirements:

· Adults: One written referral from a healthcare professional who has competencies in the assessment of transgender or gender diverse people.

· Adolescents (less than 18 years of age): One written referral from a multidisciplinary team reflecting the assessment and opinion from the team that involves both medical and mental health professionals; or separate letters collectively include assessments from both a medical and mental health professional.

· If the referral letter is from a behavioral health provider, it must include a recent diagnostic assessment.

· If the referral letter is from the member’s treating provider (physician, nurse practitioner, clinical nurse specialist), a psychosocial assessment must be completed. Include the psychosocial assessment components.

Psychosocial Assessment Components

A psychosocial assessment must include the following:

· Client’s current life situation

· Age

· Current living situation, including household membership and housing status

· Basic needs status including economic status

· Education level and employment status

· Significant personal relationships, including the member’s evaluation of relationship quality

· Strengths and resources including the extent and quality of social networks

· Belief systems

· Contextual nonpersonal factors

· General physical health and relationship to member’s culture

· Current medications

· Reason for assessment

· Description of symptoms including reason for referral

· Perception of their condition

· History of mental health treatment including review of records

· Developmental incidents

· Maltreatment or abuse

· History of alcohol or drug abuse

· Health history and family health history

· Cultural influences and impact on diagnosis and possibly on treatment

· Mental status exam

· Assessment of the member’s need based on baseline measurements, symptoms, behaviors, skills, abilities, resources, vulnerabilities and safety needs

· Screening used to determine substance abuse and other standardized screening instruments (CAGE-AID, GAIN-SS)

· Clinical summary

· Prioritization of needed mental health, ancillary or other services

· Member and family participation in assessment

· Referrals to services and service preferences by individual

· Cause, prognosis, likely consequences of symptoms

· How the criteria for a diagnosis of gender dysphoria is met: symptoms, duration and functional impairment

· Strengths, cultural influences, life situations, relationships, health concerns and how gender dysphoria diagnosis interacts with or impacts member’s life

· Primary diagnosis of gender dysphoria. If any other mental health or substance use disorders are present, to make a referral to a mental health professional or a substance use treatment specialist

Clinician Attestation

In addition to a diagnostic or psychosocial assessment, the referral letter must include the clinician’s attestation about each of the following:

· The duration of the referring provider’s relationship with the member, including the type of evaluation and therapy or counseling that the member has completed

· An explanation that the member has met criteria for surgery and a brief description of the clinical rationale for supporting the request for surgery

· A statement that the clinician obtained informed consent

· A statement that the treating provider is available for coordination of care

· Affirmation of gender dysphoria diagnosis

· If significant medical or mental health concerns are present, documentation must support that these concerns are reasonably well controlled in addition to the member’s adherence to recommended medical and behavioral treatment plans. This could include:

· Behavioral health therapy: member is receiving treatment, is in recovery, or is in stable remission of any co-morbid behavioral health conditions that are not attributed to dysphoria (for example, psychosis, trauma, substance use disorder) for 12 continuous months. Stable remission is defined as lack of hospitalization, day treatment or emergent care for any co-morbid behavioral health conditions during the 12-month period before surgery

· No medical contraindications for surgery

Billing

Bill using the MN–ITS 837I or 837P claim forms.

Refer to Billing Policy (Overview) for general billing information.