3.1 Mental Health Diagnosis and
Treatment
3.1.1 A
diagnosis of GD must be made by a TRICARE-authorized
mental health provider according to most current edition of the
DSM.
3.1.2 Psychotherapy for GD 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: ADSMs 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
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 (CPT 99366, 99367, and 99368) may be covered.
3.2 Endocrine Treatment
3.2.1 Hormone Therapy for Adults
Gender-Affirming
Hormone Therapy (GAHT), also know as
cross-sex hormone treatment is authorized in
adults if they:
3.2.1.2 Have no psychiatric comorbidity
that would confound a diagnosis of GD 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 GD.
3.2.2 Hormone Therapy for Adolescents
GAHT is authorized in
adolescents if they:
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 GD 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 GD.
3.2.3 Pubertal Suppression
3.2.3.1 Endocrine
treatment of prepubertal children is not medically
indicated until there is evidence of puberty (i.e.,
prior to Tanner stage 2) and therefore 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 GAHT may
be given.