DRAFT

Latest Review Date: July 2024

Category: Surgery

 

POLICY

Effective for dates of service October 7, 2024 and after:

I.   Criteria for All Procedures

Criteria are generally based on the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, from the World Professional Association for Transgender Health (WPATH).

Treatment of gender dysphoria may be considered medically necessary when ALL of the following diagnostic criteria are met in addition to criteria for specific procedures listed in sections II, III, IV, and V:

• A comprehensive diagnostic assessment has been completed by a health care professional with the following qualifications:
  • Are licensed  Active licensure by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution; and
  • Is experienced in the assessment and treatment of gender dysphoria, incongruence, and diversity; and
  • Has competence in the diagnosis of gender diverse identities and expressions, as well as in diagnosing possible comorbid disorders such as mood disorders, personality disorders, and substance related disorders; and
  • Has the ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria; and
  • Ability to assess capacity of the member to consent for treatment; AND
  • Participates in engagement with other health care professionals from different disciplines within the field of transgender health for consultation and referral, as needed; AND
• Based on the comprehensive evaluation, the individual meets the diagnostic criteria for gender dysphoria in adolescents and adults per the Diagnostic and Statistical Manual of Mental Health Disorders Fifth Edition, text revision (DSM 5-TR).
  • A 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:
    • A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics.
    • 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.
    • A strong desire for the primary and/or secondary sex characteristics of another gender.
    • A strong desire to be another gender
    • A strong desire to be treated as  another gender
    • A strong conviction that one has the typical feelings and reactions of another gender AND
• The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning; AND
• • Demonstrates the emotional and cognitive maturity required to provide informed consent for the treatment; AND
  • Other conditions (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been evaluated and addressed; AND
  • The relationship of the member and healthcare provider spans at least 6 months duration; AND
  •  
  • The member has been under the care of a healthcare provider for gender dysphoria for at least 6 months; AND
  • If surgical intervention is planned, the patient is a never-smoker OR has abstained from smoking, use of smokeless tobacco and/or nicotine products, and/or nicotine replacement therapy,  (not including nicotine replacement therapy (NRT)), for a minimum of 6 weeks prior to surgery; AND
• Documentation Requirements:

• One consultation letter must be provided from a qualified healthcare professional (qualifications noted above). The letter must address ALL of the following:
  • • The member's gender identifying characteristics; and
    • Results of the member's psychosocial assessment, including all diagnoses; and
    • The duration of the health professional's relationship with the member including the type of evaluation and therapy or counseling to date; and
    • If applicable, an 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
    • If applicable, a A statement that the member has been informed that WPATH Standards of Care refer to breast/chest and genital surgical treatments as “irreversible,” and that reversal of breast/chest and genital surgical treatment are not eligible for coverage prior to providing informed consent for this surgery; and
    • If applicable, a statement that minor demonstrates emotional and cognitive maturity during the informed consent/assent to treatment process; and
    • A statement that informed consent has been obtained from the member. If the member is a minor informed consent from all legal guardians and assent from the minor has been obtained; and
    • A statement that the healthcare professional is available for coordination of care.
• If surgical intervention is planned, documentation from the surgeon with recommendations for surgery AND
•  
• If surgical intervention is planned, documentation that the patient is a never-smoker OR has abstained from smoking, use of smokeless tobacco and/or nicotine products, and/or nicotine replacement therapy, for a minimum of 6 weeks prior to surgery. documentation that the patient is a never-smoker OR has abstained from smoking, use of smokeless tobacco and/or nicotine products (not including nicotine replacement therapy (NRT)) for a minimum of 6 weeks prior to surgery.

 

Note: All formats of referral documentation including narrative and assessment templates are acceptable as long as criterion items are included.

II.    Breast Surgery

• Breast surgery (mastectomy or augmentation) for treatment of gender dysphoria may be considered medically necessary when ALL of the following criteria are met:
  • Criteria in Section I are met; AND
  • Age is ONE of the following:
    • The member is 18 years of age; OR
    • Members < 18 years of age will be considered on a case-by-case basis with evidence of ALL of the following:
      1. 1. Surgeon considers intervention through a multidisciplinary team approach for eligible adolescents; and
         2. Adolescent demonstrates emotional and cognitive maturity during the informed consent/assent to treatment process.

III.  Genital Surgery

• Genital surgery for treatment of gender dysphoria may be considered medically necessary when ALL of the following criteria are met: 

• Criteria in Section I are met; AND
• Age 18 years or older; AND
• The member has completed 12 continuous months of living in the identity that is congruent with their gender identity; AND
• One of more of the following procedures:
  • • Electrolysis or laser hair removal to treat tissue donor sites for planned genital surgery;
    • Hysterectomy, salpingo-oophorectomy, orchiectomy, metoidioplasty or phalloplasty, urethroplasty, scrotoplasty, testicular prostheses, penectomy, vaginoplasty, labiaplasty, or clitoroplasty.

      ---

IV.  Reversal of Breast and Genital Surgery

• Breast and genital surgical procedures are considered irreversible, in accordance with WPATH Standards of Care, which refer to genital and breast/chest surgical treatments as “irreversible” and therefore advise that patients have sufficient time to absorb information fully before providing informed consent for these surgeries. Therefore, reversal of breast and genital surgical procedures are considered not medically necessary.
• Reversal of breast and genital surgical procedures are considered NOT MEDICALLY NECESSARY. 

V.   Additional Secondary Sex Characteristic Gender Affirming Medical and Surgical Procedures

• Non-surgical procedures for the treatment of gender dysphoria may be considered medically necessary to create and maintain gender specific characteristics as part of the overall desired GAMST treatment plan when ALL of the following criteria are met:

• Criteria in Section I are met; AND
• ONE of the following procedures:
  • Electrolysis or laser treatment for facial hair removal;
  • Voice therapy;

• Surgical procedures for the treatment of gender dysphoria The following surgical procedures may be considered medically necessary to create and maintain gender specific/non-specific characteristics as part of the overall desired GAMST treatment plan when ALL of the following criteria are met:

• Criteria in Section I are met; AND
• Age 18 years or older; AND
• One or more of the following procedures:
  • Voice modification surgery when voice/speech therapy has been ineffective;
  • Reduction thyroid chondroplasty or trachea shaving (reduction of Adam’s apple);
  • Facial surgery;
  • Face lift or liposuction, only when performed in conjunction with facial surgery;

AND

Documentation Requirements:

• For voice modification surgery, documentation from the treating speech therapy provider that speech therapy was tried and failed, and that voice modification surgery will provide further benefit.
• The following procedures do not have criteria specific to gender dysphoria and criteria for coverage are addressed in MP#058 Management of Excessive Skin and Subcutaneous Tissue:
  • Panniculectomy/Abdominoplasty 
  • Liposuction

VI.  Revision of Previous Surgery

• Revision of the initial gender-affirming surgery may be considered medically necessary for ANY of the following:
  • Surgical complication (e.g., hematoma, infection, bleeding, fistula, stricture, wound dehiscence); OR
  • A functional impairment interfering with activities of daily living (e.g. complete vaginal stenosis, urethral stricture or fistula, inability to have penetrative intercourse, difficulty with voiding while standing); OR
  • Removal and/or replacement of breast, penile, or testicular prostheses when due to complications (e.g., Baker IV contracture).
• Revision of a previous gender-affirming surgery because of dissatisfaction with appearance is considered cosmetic.

VII.  Cosmetic Procedures

• The following procedures are considered cosmetic unless otherwise addressed by member contract benefits:
  • Gluteal augmentation;
  • Pectoral implants;
  • Calf implants.

Coverage

• Preventive health screening guidelines developed for the general population are appropriate for transgender and gender diverse persons for organ systems that are unlikely to be affected by hormone therapy.
• Gender-specific preventive services are also necessary for transgender and gender diverse persons appropriate to their anatomy. Examples include the following:
  • Routine Pap smears should be performed as recommended if cervical tissue is present.
  • If mastectomy is not performed, mammograms should be performed as recommended.
  • Transgender and gender diverse persons treated with estrogen should follow the same screening guidelines for breast cancer as those for all women.
  • Screening for prostate cancer should be performed as recommended for those persons who have retained their prostate.
• Preservation of fertility is subject to the member’s contract benefits. This includes but is not limited to procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue.

Effective for dates of service July 3, 2023 through October 6, 2024:

I.   Criteria for All Procedures

Criteria are based on the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, from the World Professional Association for Transgender Health (WPATH).

Treatment of gender dysphoria may be considered medically necessary when ALL of the following diagnostic criteria are met in addition to criteria for specific procedures listed in sections II, III, IV, and V:

• A comprehensive diagnostic assessment has been completed by a health care professional with the following qualifications:
  • Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution; and
  • Is experienced in the assessment and treatment of gender dysphoria, incongruence, and diversity; and
  • Has competence in the diagnosis of gender diverse identities and expressions, as well as in diagnosing possible comorbid disorders such as mood disorders, personality disorders, and substance related disorders; and
  • Has the ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria; and
  • Ability to assess capacity to consent for treatment; AND
  • Participates in engagement with other health care professionals from different disciplines within the field of transgender health for consultation and referral, as needed; AND
• Based on the comprehensive evaluation, the individual meets the diagnostic criteria for gender dysphoria in adolescents and adults per the Diagnostic and Statistical Manual of Mental Health Disorders Fifth Edition, text revision (DSM 5-TR).
  • A 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:
    • A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics.
    • 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.
    • A strong desire for the primary and/or secondary sex characteristics of another gender.
    • A strong desire to be another gender
    • A strong desire to be treated as  another gender
    • A strong conviction that one has the typical feelings and reactions of another gender AND
• The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning; AND
• • Demonstrates the emotional and cognitive maturity required to provide informed consent for the treatment; AND
  • Other conditions (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been evaluated and addressed; AND
  • The relationship of the member and healthcare provider spans at least 6 months duration; AND
• Documentation Requirements:

• One consultation letter must be provided from a qualified healthcare professional (qualifications noted above). The letter must address ALL of the following:
  • • The member's gender identifying characteristics; and
    • Results of the member's psychosocial assessment, including all diagnoses; and
    • The duration of the health professional's relationship with the member including the type of evaluation and therapy or counseling to date; and
    • 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
    • A statement that the member has been informed that WPATH Standards of Care refer to breast/chest and genital surgical treatments as “irreversible,” and that reversal of breast/chest and genital surgical treatment are not eligible for coverage prior to providing informed consent for this surgery; and
    • A statement that informed consent has been obtained from the member. If the member is a minor informed consent from all legal guardians and assent from the minor has been obtained; and
    • A statement that the healthcare professional is available for coordination of care.
• If surgical intervention is planned, documentation from the surgeon with recommendations for surgery.

Note: All formats of referral documentation including narrative and assessment templates are acceptable as long as criterion items are included.

II.    Breast Surgery

• Breast surgery (mastectomy or augmentation) for treatment of gender dysphoria may be considered medically necessary when ALL of the following criteria are met:
  • Criteria in Section I are met; AND
  • Age is ONE of the following:
    • The member is 18 years of age; OR
    • Members < 18 years of age will be considered on a case-by-case basis with evidence of ALL of the following:
      1. 1. Surgeon considers intervention through a multidisciplinary team approach for eligible adolescents; and
         2. Adolescent demonstrates emotional and cognitive maturity during the informed consent/assent to treatment process.

III.  Genital Surgery

• Genital surgery for treatment of gender dysphoria may be considered medically necessary when ALL of the following criteria are met: 

• Criteria in Section I are met; AND
• Age 18 years or older; AND
• The member has completed 12 continuous months of living in the identity that is congruent with their gender identity; AND
• One of more of the following procedures:
  • • Electrolysis or laser hair removal to treat tissue donor sites for planned genital surgery;
    • Hysterectomy, salpingo-oophorectomy, orchiectomy, metoidioplasty or phalloplasty, urethroplasty, scrotoplasty, testicular prostheses, penectomy, vaginoplasty, labiaplasty, or clitoroplasty.

      ---

IV.  Reversal of Breast and Genital Surgery

• Breast and genital surgical procedures are considered irreversible, in accordance with WPATH Standards of Care, which refer to genital and breast/chest surgical treatments as “irreversible” and therefore advise that patients have sufficient time to absorb information fully before providing informed consent for these surgeries. Therefore, reversal of breast and genital surgical procedures are considered not medically necessary.

V.   Additional Secondary Sex Characteristic Gender Affirming Medical and Surgical Procedures

• Non-surgical procedures for the treatment of gender dysphoria may be considered medically necessary to create and maintain gender specific characteristics as part of the overall desired GAMST treatment plan when ALL of the following criteria are met:

• Criteria in Section I are met; AND
• ONE of the following procedures:
  • Electrolysis or laser treatment for facial hair removal;
  • Voice therapy;

• Surgical procedures for the treatment of gender dysphoria may be considered medically necessary to create and maintain gender specific/non-specific characteristics as part of the overall desired GAMST treatment plan when ALL of the following criteria are met:

• Criteria in Section I are met; AND
• Age 18 years or older; AND
• One or more of the following procedures:
  • Voice modification surgery when voice/speech therapy has been ineffective;
  • Reduction thyroid chondroplasty or trachea shaving (reduction of Adam’s apple);
  • Facial surgery;
  • Face lift or liposuction, only when performed in conjunction with facial surgery;

AND

Documentation Requirements:

• For voice modification surgery, documentation from the treating speech therapy provider that speech therapy was tried and failed, and that voice modification surgery will provide further benefit.
• The following procedures do not have criteria specific to gender dysphoria and criteria for coverage are addressed in MP#058 Management of Excessive Skin and Subcutaneous Tissue:
  • Panniculectomy/Abdominoplasty 
  • Liposuction

VI.  Revision of Previous Surgery

• Revision of the initial gender-affirming surgery may be considered medically necessary for ANY of the following:
  • Surgical complication (e.g., hematoma, infection, bleeding, fistula, stricture, wound dehiscence); OR
  • A functional impairment interfering with activities of daily living (e.g. complete vaginal stenosis, urethral stricture or fistula, inability to have penetrative intercourse, difficulty with voiding while standing); OR
  • Removal and/or replacement of breast, penile, or testicular prostheses when due to complications (e.g., Baker IV contracture).
• Revision of a previous gender-affirming surgery because of dissatisfaction with appearance is considered cosmetic.

VII.  Cosmetic Procedures

• The following procedures are considered cosmetic unless otherwise addressed by member contract benefits:
  • Gluteal augmentation;
  • Pectoral implants;
  • Calf implants.

Coverage

• Preventive health screening guidelines developed for the general population are appropriate for transgender and gender diverse persons for organ systems that are unlikely to be affected by hormone therapy.
• Gender-specific preventive services are also necessary for transgender and gender diverse persons appropriate to their anatomy. Examples include the following:
  • Routine Pap smears should be performed as recommended if cervical tissue is present.
  • If mastectomy is not performed, mammograms should be performed as recommended.
  • Transgender and gender diverse persons treated with estrogen should follow the same screening guidelines for breast cancer as those for all women.
  • Screening for prostate cancer should be performed as recommended for those persons who have retained their prostate.
• Preservation of fertility is subject to the member’s contract benefits. This includes but is not limited to procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue.

DESCRIPTION OF PROCEDURE OR SERVICE

Gender affirming medical and surgical treatment (GAMST) is part of the spectrum of care considered for transgender and gender diverse (TGD) individuals. Gender dysphoria refers to the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s sex assigned at birth. TGD individuals may have a gender that blends elements of both genders or doesn’t identify with any gender. The spectrum of gender identities experienced by TGD individuals may include identities such as non-binary, agender, gender fluid, and others. For this policy, the symptoms experienced by all TGD individuals will be referred to as gender dysphoria, recognizing that the spectrum of symptoms may vary from person to person. The therapeutic approach to gender dysphoria are outlined by the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 from the World Professional Association for Transgender Health (WPATH). Treatment may involve multiple subspecialties, including but not limited to, primary care, speech and language therapy, endocrinology, dermatology, mental health, physical therapy, and surgical modalities. Gender affirming care interventions and/or GAMSTs consist of a variety of services that may differ from person to person. These include,but are not limited to, psychological and social interventions, social transition, and/or treatment with hormones and/or surgery to change the genitalia and other sex characteristics.

Definitions:

Nicotine: A highly addictive chemical compound present in a tobacco plant. All tobacco and non-tobacco nicotine (NTN) products contain nicotine. Examples of nicotine products include cigarettes, non-combusted cigarettes, cigars, smokeless tobacco (e.g., dip, snuff, snus, chewing tobacco), hookah tobacco, e-cigarettes, and vape pens.

Nicotine Replacement Therapy (NRT): Products designed to help adults quit smoking by delivering small amounts of nicotine to the brain without the toxic chemicals found in cigarette smoke. Examples include skin patches, gum, and lozenges.

KEY POINTS:

Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the previous version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8, published in 2022. Revised standards of care in the field of gender care are aimed at improving safe and effective pathways to enhance access of care throughout the lifespan.

In 2021, Valentine and Shipherd reported a systematic review of 77 studies published which reported mental health outcomes to (a) characterize what is known about mental health outcomes and (b) describe what gaps persist in this literature. In general, depressive symptoms, suicidality, interpersonal trauma exposure, substance use disorders, anxiety, and general distress have been consistently elevated among Transgender and gender non-conforming (TGNC) adults. This study emphasizes that “depressive symptoms, suicidality, interpersonal trauma exposure, substance use disorders, anxiety, and general distress have been consistently elevated among transgender and gender non-conforming (TGNC) population…Findings suggest that TGNC people are exposed to a variety of social stressors, including stigma, discrimination, and bias events that contribute to mental health problems.” Additional study is necessary to emphasize changes in mental health problems across studies using similar measurements across models to evaluate the growing evidence as a whole.

Ainsworth and Spiegel (2010) published a study that assessed quality of life outcomes of transgender patients who underwent facial gender confirming surgery in combination with genital or breast surgery. Included in the study were 247 transgender females. Mental health quality of life was assessed in transgendered women without surgical intervention compared to the general female population, and transgendered women who had gender reassignment surgery (GRS), facial feminization surgery (FFS), or both. Mental health-related quality of life was statistically diminished (P < 0.05) in transgendered women without surgical intervention compared to the general female population and transwomen who had gender reassignment surgery (GRS), facial feminization surgery (FFS), or both. Investigators concluded that transgender women have diminished mental health-related quality-of-life compared with the general female population. However, surgical treatments (e.g., FFS, GRS, or both) are associated with improved mental health-related quality of life.

Wernick, et al (2019), in acknowledging that a paucity of research exists related to the effect of surgical intervention on individuals with gender dysphoria, despite the disproportionate mental health risks, undertook a review of the evidence surrounding quality of life and gender-confirmation surgery. Investigators’ aim was to examine existing literature for an understanding of the impact of gender affirming surgery, and to understand to what extent the surgical intervention could improve psychological well-being. 17 studies were identified. Investigators found that “most studies included in this review found that many GAS [gender affirming surgeries] have a significant, positive impact on several constructs associated with psychological well-being. Findings from this review suggest that individuals with gender dysphoria who undergo facial feminization or masculinization, vocal feminization, breast augmentation, mastectomy, chest reconstruction, metoidioplasty, orchiectomy, salpingooophorectomy, vaginoplasty, or phalloplasty may experience significant improvements in quality of life, body image/satisfaction, and overall psychiatric functioning.” Future research should be focused on understanding how specific GAS affects mental health status over time.

Morrison et al (2020) published a prospective, international, multicenter, cohort study with adult gender-diverse patients with gender dysphoria (n=66). Authors noted that facial feminization surgery plays a critical role in gender affirmation; as the face is one of the most visible external indicators of gender, typically masculine features make it difficult for transfeminine individuals to be perceived as their correct gender. This study set out to determine the effects of facial feminization surgery on quality-of-life outcomes.

Facial feminization outcome score was calculated preoperatively and postoperatively (1-week to 1-month and >6 months). Patients noted that their brows, jaws, and chins were the most masculine aspects of their faces (54.5 percent, 33.3 percent, and 30.3 percent, respectively). Following surgery, median facial feminization outcome score increased from 47.2 preoperative to 80.6 at 6 months or more postoperatively (p < 0.0001). Mean satisfaction was excellent (3.0 at both 1-month and ≥6-month follow-up; p = 0.46). Cephalometric values were significantly more feminine following surgery. Investigators concluded that facial feminization achieved improved quality of life, feminized cephalometries, feminine gender appearance, good overall aesthetics, and high satisfaction that were present at 1 month and stable at more than 6 months.

The findings that current smokers have a higher risk of wound infection and wound disruption can be explained by the pathophysiological mechanisms related to the toxic effects and oxidative destruction induced by smoking and nicotine. Smoking impedes the innate defense system of the lung, including damaging mucus transport, aggravating mucus production, and diminishing macrophage function, resulting in increased risk of pulmonary complications. While NRT contains nicotine, it contains lower amounts without other carcinogens, and the impact on the body is more gradual. Plasma nicotine levels provided by NRT vary according to dose and delivery method but in general are lower than those maintained during active smoking. The exclusion of NRT will remove barriers to accessing surgical care and promote overall smoking cessation, while promoting consistency with clinical guidelines.  

In 2022, Chiang et al published results on a retrospective, cohort study of 1,156,002 patients, utilizing files of the American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression was used to calculate the odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative wound complications, pulmonary complications, and in-hospital mortality associated with smokers. Smoking was associated with a significantly increased risk of postoperative wound disruption (OR 1.65, 95% CI 1.56-1.75), surgical site infection (OR 1.31, 95% CI 1.28-1.34), reintubation (OR 1.47, 95% CI 1.40-1.54), and in-hospital mortality (OR 1.13, 95% CI 1.07-1.19) compared with nonsmoking. The length of hospital stay was significantly increased in smokers compared with non-smokers. They found that current smokers who underwent surgery had approximately 30% increased odds of developing surgical site infection (SSI) and 65% increased odds of developing wound disruption. Study conclusions state smoking status is related to increased perioperative risk for wound complications following major surgical procedures. The current literature review has shown that smoking harms wound healing. The study adds to existing evidence and improves understanding of healing complications in smoking surgical cases. Wound complications are associated with other adverse outcomes and have a significant impact on patient quality of life and health care budgets. Therefore, patients who smoke should be informed about the potentially increased risks of complications before surgery.

In 2022, Liu et al published a meta-analysis on the effect of preoperative smoking and smoking cessation on wound healing and infection in post-surgery subjects. This analysis incorporated 11 trials involving 218,567 patients following surgery; 176,670 were previous or non-smokers, and 41,897 were smokers. Never smokers or those who had ceased smoking had significantly lower postoperative wound healing problems (odds ratio 0.74; 95% CI 0.63-0.87, p < .001) compared with smokers. Non-smokers had significantly lower postoperative wound healing problems and surgical site wound infection compared with smokers.

Sorensen et al (2012) reported on the results of a meta-analysis that sought to clarify the evidence on smoking and postoperative healing complications across surgical specialties and determine the impact of perioperative smoking cessation intervention. Smokers and non-smokers were compared in 140 cohort studies that included 479K patients. Pooled adjusted odds ratios (95% CI) were 3.60 (2.62 - 4.93) for necrosis, 2.07 (1.53-2.81) for healing delay and dehiscence, 1.79 (1.57-2.04) for surgical site infection, 2.27 (1.82-2.84) for wound complications, 2.07 (1.23-3.47) for hernia, and 2.44 (1.66-3.58) for lack of fistula or bone healing. Investigators concluded that postoperative healing complications occur significantly more often in smokers compared with non-smokers and in former smokers compared with those who never smoked.

Nolan and Warner (2015) authored a narrative review to discuss the current evidence for nicotine replacement therapy’s (NRT)efficacy and safety in patients scheduled for surgical treatment and other invasive procedures. Noting the lack of human trials, the authors stated that although available data are limited, there is no evidence from human studies that NRT increases the risk of healing-related or cardiovascular complications. Clinical trials of tobacco use interventions that include NRT have found either no effect or a reduction in complications. Authors concluded that given the benefits of smoking abstinence to both perioperative outcomes and long-term health and the efficacy of NRT in achieving and maintaining abstinence, any policies that prohibit the use of NRT in surgical patients should be reexamined.

In 2020, Stefan et al reported on a retrospective study (n=147,506). Researchers analyzed the association between nicotine replacement therapy (within 2 days of admission) and inpatient complications and outcomes. In the propensity-matched analysis, there was no association between receipt of NRT and in-hospital complications (OR, 0.99; 95% CI, 0.93-1.05), mortality (OR, 0.84; 95% CI, 0.68-1.04), all-cause 30-day readmissions (OR, 1.02; 95% CI, 0.97-1.07), or 30-day readmission for wound complications (OR, 0.96; 95% CI, 0.86-1.07). Authors concluded that this demonstrates that perioperative NRT is not associated with adverse outcomes after surgery. These results strengthen the evidence that NRT should be prescribed routinely in the perioperative period.

Practice Guidelines and Position Statements

American Academy of Pediatrics

Any discrimination based on gender identity or expression, real or perceived, is damaging to the socioemotional health of children, families, and society.  In particular, the AAP recommends the following, among other recommendations:

1. that youth who identify as TGD have access to comprehensive, gender-affirming, and developmentally appropriate health care that is provided in a safe and inclusive clinical space;
2. that insurance plans offer coverage for health care that is specific to the needs of youth who identify as TGD, including coverage for medical, psychological, and, when indicated, surgical gender-affirming interventions;
3. that the medical field and federal government prioritize research that is dedicated to improving the quality of evidence-based care for youth who identify as TGD

The American Academy of Pediatrics takes a “gender-affirming,” nonjudgmental approach that helps children feel safe in a society that too often marginalizes or stigmatizes those seen as different. The gender affirming model strengthens family resiliency and takes the emphasis off heightened concerns over gender while allowing children the freedom to focus on academics, relationship-building and other typical developmental tasks. Additional AAP recommendations include:

• Providing youth with access to comprehensive gender-affirming and developmentally appropriate health care.
• Providing family-based therapy and support be available to meet the needs of parents, caregivers and siblings of youth who identify as transgender.
• Making sure that electronic health records, billing systems, patient centered notification systems and clinical research are designed to respect the asserted gender identity of each patient while maintaining confidentiality.
• Supporting insurance plans that offer coverage specific to the needs of youth who identify as transgender, including coverage for medical, psychological and, when appropriate, surgical interventions.
• Advocacy by pediatricians within their communities, for policies and laws that seek to promote acceptance of all children without fear of harassment, exclusion or bullying because of gender expression.

American Psychological Association (APA)’s Society for Pediatric Psychology Special Interest Group for Gender Health 

• Transgender and gender-diverse (TGD) youth experience significant mental health disparities, including increased suicidality. Gender affirming healthcare can be a life-saving intervention.
• Access to timely gender-affirming medical interventions during puberty and adolescence is critical to promoting positive mental health outcomes.
• Restricting access to gender-affirming care is healthcare discrimination and will perpetuate health disparities. 

Diagnostic and Statistical Manual of Mental Disorders Version V, Text Revision (DSM-V-TR)

The recently published text revision of DSM-V, AND provides the criteria for diagnosis of gender dysphoria as well as information on the overarching diagnosis of gender dysphoria:

• Gender dysphoria refers to the distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender. Although not all indi¬ viduals will experience distress as a result of such incongruence, many are distressed if the desired physical interventions by means of hormones and/or surgery are not available. The current term is more descriptive than the previous DSM-IV term gender identity disor¬ der and focuses on dysphoria as the clinical problem, not identity per se.

Association of American Medical Colleges-AAMC Statement on Gender-affirming Health Care for Transgender Youth

The AAMC is committed to ensuring access to high-quality care that treats all people, including transgender individuals, equally and with respect, and providing training to physicians and other health care professionals that is consistent with those values.  In medical decision making, the doctor-patient relationship must be paramount, and the needs of the patient must be given precedence. Efforts to restrict the provision of gender-affirming health care for transgender individuals will reduce health care access for transgender Americans, promote discrimination, and widen already significant health inequities. In addition to harming some of the most vulnerable patients, efforts to restrict care undermine the doctor-patient relationship and the principle that doctors are best equipped to work with patients and their families to arrive at shared decision-making. The AAMC is committed to improving the health of all people everywhere, and we will continue to oppose any effort to restrict the health care community’s ability to provide necessary care to any patient in need. Scientific research supports the effectiveness of gender-affirming medical care (GAMC) for the mental health and quality of life of transgender youth, dispelling misinformation upon which anti-GAMC policy initiatives are based.

The Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 from the World Professional Association for Transgender Health (WPATH)  

Extensive updates and changes in recommendations were made in the newest World Professional Association for Transgender Health (WPATH version. Guidelines encourage the use of a patient centered care model for initiation of gender affirming interventions and update many previous requirements to reduce barriers to access. These include but are not limited to nomenclature changes, healthcare provider requirements, referral specifics, hormone therapy use, and patient autonomy considerations.

The Society for Perioperative Assessment and Quality Improvement (SPAQI)

In 2020, the Society for Perioperative Assessment and Quality Improvement (SPAQI) convened a multidisciplinary panel of 17 experts in perioperative smoking cessation. Members of the Task Force were from the fields of anesthesiology, internal medicine, surgery, public health, and pharmacy from both academic and nonacademic settings in Canada, United States, Australia, New Zealand, Asia, and Europe. The panel issued the following consensus statement: Interventions should occur as soon as practicable in relation to surgical scheduling. Evidence from observational studies of spontaneous quitting suggests that longer durations of preoperative abstinence are associated with lower rates of respiratory and wound healing complications. Evidence from RCTs supports an effect of preoperative smoking cessation interventions that are 4–8 weeks long.

The National Comprehensive Cancer Network (NCCN)

In 2024, The National Comprehensive Cancer Network (NCCN) published guidelines on smoking cessation. The guideline states the following:

"Nicotine replacement therapy (NRT) is not a contraindication to surgery. There is no evidence that NRT degrades the wound-healing benefits of abstinence from smoking in humans. NRT offers benefits over continued smoking. NRT typically provides less nicotine than cigarettes, and nearly doubles the chance of smoking abstinence."

BENEFIT APPLICATION

Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.

ITS: Covered if covered by the Participating Home Plan

FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan.

CURRENT CODING:

CPT Codes:

11950	Subcutaneous injection of filling material (eg, collagen); 1 cc or less
11951	Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc
11952	Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc
11954	Subcutaneous injection of filling material (eg, collagen); over 10.0 cc
14000	Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
14001	Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
14041	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
15734	Muscle, myocutaneous, or fasciocutaneous flap; trunk
15738	Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
15750	Flap; neurovascular pedicle
15757	Free skin flap with microvascular anastomosis
15758	Free fascial flap with microvascular anastomosis
15769	Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
15771	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
15772	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure)
15773	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate
15774	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure)
15819	Cervicoplasty
15820	Blepharoplasty, lower eyelid;
15821	Blepharoplasty, lower eyelid; with extensive herniated fat pad
15822	Blepharoplasty, upper eyelid;
15823	Blepharoplasty, upper eyelid; with excessive skin weighting down lid
15824	Rhytidectomy; forehead
15825	Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)
15826	Rhytidectomy; glabellar frown lines
15828	Rhytidectomy; cheek, chin, and neck
15829	Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap
15830	Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
15832	Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
15833	Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
15834	Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
15835	Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock
15836	Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
15837	Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand
15838	Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad
15839	Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area
15847	Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)
15876	Suction assisted lipectomy; head and neck
15877	Suction assisted lipectomy; trunk
15878	Suction assisted lipectomy; upper extremity
15879	Suction assisted lipectomy; lower extremity
17380	Electrolysis epilation, each 30 minutes
17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue
19316	Mastopexy
19318	Breast reduction
19325	Breast augmentation with implant
19340	Insertion of breast implant on same day of mastectomy (ie, immediate)
19342	Insertion or replacement of breast implant on separate day from mastectomy
19350	Nipple/areola reconstruction
21120	Genioplasty; augmentation (autograft, allograft, prosthetic material)
21121	Genioplasty; sliding osteotomy, single piece
21122	Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin)
21123	Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)
21125	Augmentation, mandibular body or angle; prosthetic material
21127	Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)
21137	Reduction forehead; contouring only
21138	Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)
21139	Reduction forehead; contouring and setback of anterior frontal sinus wall
21172	Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts)
21175	Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts)
21179	Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material)
21180	Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts)
21208	Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)
21209	Osteoplasty, facial bones; reduction
21210	Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
21270	Malar augmentation, prosthetic material
21899	Unlisted procedure, neck or thorax
30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
30410	Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
30420	Rhinoplasty, primary; including major septal repair
30430	Rhinoplasty, secondary; minor revision (small amount of nasal tip work)
30435	Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
30450	Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)
31599	Unlisted procedure, larynx
31899	Unlisted procedure, trachea, bronchi
40799	Unlisted procedure, lips
53410	Urethroplasty, 1-stage reconstruction of male anterior urethra
53430	Urethroplasty, reconstruction of female urethra
54125	Amputation of penis; complete
54400	Insertion of penile prosthesis; non-inflatable (semi-rigid)
54401	Insertion of penile prosthesis; inflatable (self-contained)
54405	Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir
54406	Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis
54408	Repair of component(s) of a multi-component, inflatable penile prosthesis
54410	Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session
54411	Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue
54415	Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis
54416	Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session
54417	Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue
54520	Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach
54660	Insertion of testicular prosthesis (separate procedure)
54690	Laparoscopy, surgical; orchiectomy
55175	Scrotoplasty; simple
55180	Scrotoplasty; complicated
55970	Intersex surgery; male to female
55980	Intersex surgery; female to male
56620	Vulvectomy simple; partial
56625	Vulvectomy simple; complete
56800	Plastic repair of introitus
56805	Clitoroplasty for intersex state
57110	Vaginectomy, complete removal of vaginal wall;
57291	Construction of artificial vagina; without graft
57292	Construction of artificial vagina; with graft
57335	Vaginoplasty for intersex state
58150	Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);
58180	Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)
58260	Vaginal hysterectomy, for uterus 250 g or less;
58262	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)
58275	Vaginal hysterectomy, with total or partial vaginectomy;
58290	Vaginal hysterectomy, for uterus greater than 250 g;
58291	Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58541	Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less;
58542	Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58543	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g;
58544	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58550	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less;
58552	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58553	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g;
58554	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58570	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less;
58571	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58572	Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;
58573	Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58661	Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
58720	Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
58940	Oophorectomy, partial or total, unilateral or bilateral;
64856	Suture of major peripheral nerve, arm or leg, except sciatic; including transposition
64892	Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length
64896	Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; more than 4 cm length
67900	Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals
92524	Behavioral and qualitative analysis of voice and resonance
96158	Health behavior intervention, individual, face-to-face; initial 30 minutes
96159	Health behavior intervention, individual, face-to-face; each additional 15 minutes (List separately in addition to code for primary service)

REFERENCES:

1. Ainsworth TA, Spiegel JH. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Qual Life Res. 2010;19(7):1019-1024.
2. Alverdy JC, Prachand V. Smoking and Postoperative Surgical Site Infection: Where There's Smoke, There's Fire. JAMA Surg. 2017;152(5):484.
3. American Academy of Pediatrics (2018). Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics, 142(4), e20182162.
4. American Medical Association, Issue Brief (2019). Health insurance coverage for gender affirming care of transgender patients. www.ama-assn.org/system/files/2019-03/transgender-coverage-issue-brief.pdf.
5. American Psychiatric Association (2021). (APA)’s Division 54 Society for Pediatric Psychology Special Interest Group for Gender Health. www.apa.org/topics/lgbtq/division-54-statement-gender-affirmative-care.pdf.
6. American Psychiatric Association Diagnostic and statistical manual of mental disorders, fifth edition, text revision. Washington: American Psychiatric Association, 2022
7. Association of American Medical Colleges (2019) AAMC Statement on Gender-Affirming Health Care for Transgender Youth. www.aamc.org/news-insights/press-releases/aamc-statement-gender-affirming-health-care-transgender-youth.
8. Association of American Medical Colleges Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development. In: Hollenback AD, Eckstrand KL, Dreger A, eds. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born With DSD: A Resource for Medical Educators. Washington, DC: Association of American Medical Colleges; 2014. members.aamc.org/eweb/upload/Executive LGBT FINAL.pdf. Accessed August 8, 2018
9. Berli JU, Capitán L, Simon  D, et al. Facial gender confirmation surgery—review of the literature and recommendations for Version 8 of the WPATH Standards of Care. Int J Transgenderism. 2017 Apr;18:3, 264-270.
10. Boyer TL, Wolfe HL, Littman AJ, Shipherd JC, Kauth MR, Blosnich JR. Patient Experiences and Provider Perspectives on Accessing Gender-Affirming Surgical Services in the Veterans Health Administration. J Gen Intern Med. 2023;38(16):3549-3557.
11. Byne W, Bradley SJ, Coleman E, et al. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Arch Sex Behav. 2012;41(4):759-796.
12. Capitán L, Simon D, Berli JU, et al. Facial Gender Confirmation Surgery: A New Nomenclature. Plast Reconstr Surg. 2017;140(5):766e-767e.
13. Clinical input. Gender Health Specialist Received April 2023.
14. Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People. 7th Edition. World Professional Association for Transgender Health. 2012. 
15. Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the   Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022;23(Suppl 1):S1-S259. Published 2022 Sep 6.
16. Durwood L, McLaughlin KA, Olson KR. Mental Health and Self-Worth in Socially Transitioned Transgender Youth [published correction appears in J Am Acad Child Adolesc Psychiatry. 2018 Nov;57(11):899. J Am Acad Child Adolesc Psychiatry. 2017;56(2):116-123.e2.
17. Edwards-Leeper L, Spack NP. Psychological evaluation and medical treatment of transgender youth in an interdisciplinary "Gender Management Service" (GeMS) in a major pediatric center. J Homosex. 2012;59(3):321-336.
18. Fan Chiang YH, Lee YW, Lam F, Liao CC, Chang CC, Lin CS. Smoking increases the risk of postoperative wound complications: A propensity score-matched cohort study. Int Wound J. 2023;20(2):391-402.
19. Fisher M, Lu SM, Chen K, Zhang B, Di Maggio M, Bradley JP. Facial Feminization Surgery Changes Perception of Patient Gender. Aesthet Surg J. 2020;40(7):703-709.
20. Grønkjær M, Eliasen M, Skov-Ettrup LS, et al. Preoperative smoking status and postoperative complications: a systematic review and meta-analysis. Ann Surg. 2014;259(1):52-71.
21. Liu D, Zhu L, Yang C. The effect of preoperative smoking and smoke cessation on wound healing and infection in post-surgery subjects: A meta-analysis. Int Wound J. 2022 Apr 22. Online ahead of print.
22. Minnesota Department of Human Service (DHS). MHCP Provider Manual. Gender Affirming Surgery. Revised September 8, 2023.
23. Morrison SD, Capitán-Cañadas F, Sánchez-García A, et al. Prospective Quality-of-Life Outcomes after Facial Feminization Surgery: An International Multicenter Study. Plast Reconstr Surg. 2020;145(6):1499-1509.
24. National Comprehensive Cancer Network. Smoking Cessation (Version 1.2024). www.nccn.org/professionals/physician_gls/pdf/smoking.pdf
25. Nolan MB, Warner DO. Safety and Efficacy of Nicotine Replacement Therapy in the Perioperative Period: A Narrative Review. Mayo Clin Proc. 2015;90(11):1553-1561.

26. Olson-Kennedy J, Warus J, Okonta V, Belzer M, Clark LF. Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts. JAMA Pediatr. 2018;172(5):431-436.

27. Owen-Smith AA, Gerth J, Sineath RC, et al. Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction, and Mental Health in a Cohort of Transgender Individuals. J Sex Med. 2018;15(4):591-600.
28. Rafferty J, American Academy of Pediatrics, Committee on Psychological Aspects of Child and Family Health, Committee on Adolescence, and Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. Sep 17 2018; 142:1-15.
29. Sørensen LT. Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: a systematic review and meta-analysis. Arch Surg. 2012;147(4):373-383.
30. Stefan MS, Pack Q, Shieh MS, et al. The Association of Nicotine Replacement Therapy with Outcomes Among Smokers Hospitalized for a Major Surgical Procedure. Chest. 2020;157(5):1354-1361.
31. Straub JJ, Paul KK, Bothwell LG, et al. Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery [published correction appears in Cureus. 2024 Jun 11;16(6):c182. Cureus. 2024;16(4):e57472. Published 2024 Apr 2.
32. U.S. Food and Drug Administration, Products, Guidance and Regulations. Updated June 3, 2020. www.fda.gov/tobacco-products/products-guidance-regulations
33. U.S. Food and Drug Administration. Tobacco, June 29, 2022. www.fda.gov/tobacco-products/products-ingredients-components/e-cigarettes-vapes-and-other-electronic-nicotine-delivery-systems-ends
34. Valentine SE, Shipherd JC. A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clin Psychol Rev. 2018;66:24-38.
35. Wernick JA, Busa S, Matouk K, Nicholson J, Janssen A. A Systematic Review of the Psychological Benefits of Gender-Affirming Surgery. Urol Clin North Am. 2019;46(4):475-486.
36. Stefan MS, Pack Q, Shieh MS, et al. The Association of Nicotine Replacement Therapy with Outcomes Among Smokers Hospitalized for a Major Surgical Procedure. Chest. 2020;157(5):1354-1361.

37. U.S. Food and Drug Administration, Products, Guidance and Regulations. Updated June 3, 2020. www.fda.gov/tobacco-products/products-guidance-regulations
38. U.S. Food and Drug Administration. Tobacco, June 29, 2022. www.fda.gov/tobacco-products/products-ingredients-components/e-cigarettes-vapes-and-other-electronic-nicotine-delivery-systems-ends
39. Valentine SE, Shipherd JC. A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clin Psychol Rev. 2018 Dec;66:24-38.
40. Wernick JA, Busa S, Matouk K, et al. A systematic review of the psychological benefits of gender-affirming surgery. Urol Clin North Am. 2019 Nov;46(4):475-486.
41. Wong J, An D, Urman RD, et al. Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement on Perioperative Smoking Cessation. Anesth Analg. 2020;131(3):955-968.

POLICY HISTORY:

Reviewed and posted July 1, 2021.

December 2021: Policy Statement updated to add coverage criteria for revision of initial genital affirming surgery, effective January 31, 2022. Posted for Draft December 1, 2021 through January 30, 2022.

March 2022: Annual review completed. No change to policy intent.

April 2023: Annual review completed. Update to Title and Description. Policy Statement updated with WPATH, Version 8 criteria. Update to Current Coding section- codes 92524, 96158, 96159 added. Policy on draft May 18, 2023 through July 2, 2023.

July 2024: Annual review completed. Update to Description. Clarifications made to Policy Statement. Updates added to criterion regarding smoking cessation and removed documentation requirements for voice modification surgery. Policy on draft July 19, 2024 through September 1, 2024.

August 2024: Ad Hoc review- Policy statement update- requirement for cessation of “nicotine replacement therapy (NRT)” removed. Description updated. Added Key Points and References sections. Draft period extended, July 19, 2024 through October 6, 2024.

 

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1.  The technology must have final approval from the appropriate government regulatory bodies;
2.  The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3.  The technology must improve the net health outcome;
4.  The technology must be as beneficial as any established alternatives;
5.  The improvement must be attainable outside the investigational setting.

 

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1.  In accordance with generally accepted standards of medical practice; and
2.  Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3.  Not primarily for the convenience of the patient, physician or other health care provider; and
4.  Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.