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:
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 Medical 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 TRICARE Prime Remote (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
(Current Procedural Terminology (CPT) codes 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 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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