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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