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TRICARE Policy Manual 6010.60-M, April 1, 2015
Medicine
Chapter 7
Section 1.2
Gender Dysphoria
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-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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