Medicine
Chapter 7
Section 1.2
Gender
Dysphoria (GD) Health Care For Dates of Service On
or Before June 30, 2022
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-105, December 6, 2022
1.0 DESCRIPTION
GD 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
GD.
2.2 Surgical treatment of GD for
non-active duty beneficiaries is prohibited by statute (10 USC 1079). Benefits
may be available for Active Duty Service Members (ADSMs) under the
Supplemental Health Care Program (SHCP).
3.0 POLICY CONSIDERATIONS
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.
4.0 EXCLUSIONS
4.1 All services
and supplies directly and or indirectly related to surgical treatment
for GD (i.e., gender-affirming
surgical procedures), 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 GD.
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