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TRICARE Policy Manual 6010.60-M, April 1, 2015
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
Authority:  32 CFR 199.4(e)(8)(ii)(D), (g)(29), and (g)(30); and Title 10, United States Code (USC) 1079(a)(11)
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:
3.2.1.1  Have a diagnosis of GD as described in paragraph 3.1.1;
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:
3.2.2.1  Have a diagnosis of GD 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 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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