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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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