Medicine
Chapter 7
Section 1.2
Gender Dysphoria
Issue Date: September 6, 2016
Copyright: CPT
only © 2006 American Medical Association (or such other date of
publication of CPT).
All Rights Reserved.
Revision: C-13, November 15, 2017
1.0 DESCRIPTION
Gender dysphoria is a condition where a person
experiences clinically significant distress, or impairment in social,
occupational, or other important area of functioning, of at least
six months duration, because of a marked incongruence between the
gender assigned, usually at birth (i.e., natal sex) and their experienced/expressed
gender identity. The clinical definition is provided in the Diagnostic
and Statistical Manual of Mental Disorders (DSM), Fifth Edition
(May, 2013). Diagnosis is to be made using the most current edition
of the DSM.
2.0 POLICY
2.1 Medically
or psychologically necessary (as defined in
32 CFR 199.2)
and appropriate medical care (as defined in
32 CFR 199.2)
may be covered for non-surgical treatment of gender dysphoria.
2.2 Surgical
treatment of gender dysphoria for non-active duty beneficiaries
is prohibited by statute (10 USC 1079).
3.0 POLICY
CONSIDERATIONS
3.1 Mental
Health Diagnosis and Treatment
3.1.1 A
diagnosis of gender dysphoria must be made by a TRICARE-authorized
mental health provider according to most current edition of the
DSM.
3.1.2 Psychotherapy for gender dysphoria and psychotherapy
rendered for patients pursuing transition (e.g., during “Real-Life
Experience,” or RLE) by a TRICARE-authorized mental health provider
is covered.
3.1.3 Consistent with mental health treatment for
other disorders, outpatient
, office-based, mental
health visits do not require
a referral or preauthorization.
Note: Active duty members require Military Treatment
Facility (MTF) referral/authorization or Specified Authorized Staff
(SAS) preauthorization prior to receiving non-emergency health care services
(other than primary health care for members enrolled in TPR) in
the private sector. The contractor shall comply with the provisions
of the TRICARE Operations Manual (TOM),
Chapters 16 and
17 when processing requests for active duty
members.
3.1.4 Treatment team conferences
(CPT 99366, 99367, and 99368) may be covered.
3.2 Endocrine
Treatment
3.2.1 Hormone
Therapy for Adults
Cross-sex hormone treatment
in adults is authorized if they:
3.2.1.1 Have a
diagnosis of gender dysphoria as described in
paragraph 3.1.1;
3.2.1.2 Have no
psychiatric comorbidity that would confound a diagnosis of gender
dysphoria or interfere with treatment (e.g., unresolved body dysmorphic
disorder; schizophrenia or other psychotic disorders that have not
been stabilized with treatment); and
3.2.1.3 Have a
documented minimum of three months of RLE and/or three months of
continuous psychotherapy addressing gender transition as an intervention
for gender dysphoria.
3.2.2 Hormone Therapy for Adolescents
Cross-sex hormone treatment in adolescents
is authorized if they:
3.2.2.1 Have a
diagnosis of gender dysphoria as described in
paragraph 3.1.1;
3.2.2.2 Have experienced
puberty to at least Tanner stage 2;
3.2.2.3 Are 16
years or older;
3.2.2.4 Have no
psychiatric comorbidity that would confound a diagnosis of gender
dysphoria or interfere with treatment (e.g., unresolved body dysmorphic
disorder; schizophrenia or other psychotic disorders that have not
been stabilized with treatment); and
3.2.2.5 Have a
documented minimum of three months RLE and/or three months of continuous psychotherapy
addressing gender transition as an intervention for gender dysphoria.
3.2.3 Pubertal
Suppression
3.2.3.1 Because a diagnosis of gender dysphoria in
a prepubertal child may resolve (a majority of childhood cases do
not persist into adolescence), endocrine treatment of prepubertal
children (i.e., prior to Tanner stage 2) is not authorized.
3.2.3.2 Adolescents
who have experienced puberty to at least Tanner stage 2 may be treated
by suppressing puberty with gonadotropin-releasing hormone (GnRH)
analogues until age 16 years old, after which cross-sex hormones
may be given.
4.0 EXCLUSIONS
4.1 All services
and supplies directly and or indirectly related to surgical treatment
for gender dysphoria (i.e., sex gender change), to include oophorectomy
and orchiectomy, except when performed to correct ambiguous genitalia,
which is documented to have been present at birth (CPT procedure
codes 55970 and 55980).
4.2 Cosmetic, reconstructive or
plastic surgery procedures are excluded from coverage (see
Chapter 4, Section 2.1).
4.3 Endocrine treatment of prepubertal children
prior to Tanner Stage 2 is excluded.
5.0 EFFECTIVE
DATE
October 3, 2016, for non-surgical treatment
of gender dysphoria.
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