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Health Insurance Medical Policies - Youth Services


Below are excerpts from various health insurance medical policies that have explicit provisions detailing when treatments for gender dysphoria (such as puberty suppression or surgery) are covered for transgender people under 18.

The fact that an insurance company is listed here does not mean that your particular plan will follow these guidelines. You must look to your individual policy to determine if transgender care is covered or excluded. Only if it is covered will the policies below apply.

Policy: Gonadotropin-Releasing Hormone Analogs and Antagonists

Youth Services:

Aetna considers leuprolide (Lupron, Viadur, Eligard) medically necessary for the following indications subject to the specified limitations:

  • To suppress onset of puberty in transgender adolescents if they meet WPATH criteria (see Appendix).
  • For female to male transgender persons, to stop menses prior to testosterone treatment and to reduce estrogens to levels found in biological males.
  • To reduce testosterone levels in male to female transgender persons.

Aetna considers histrelin acetate implants experimental and investigational for all other indications (e.g., precocious puberty due to adrenal hyperplasia, and suppression of onset of puberty in transgender adolescents) because there is insufficient evidence in the peer-reviewed literature.

Policy: Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indic…

Youth Services:

Gender Dysphoria in Adolescents

Medically Necessary:

  1. GnRH analogs are considered medically necessary for adolescents with gender dysphoria when all of the following criteria are met:
    1. Fulfills the DSM V criteria for gender dysphoria; and
    2. Has experienced puberty to at least Tanner stage 2; and
    3. Has (early) pubertal changes that have resulted in an increase of their gender dysphoria; and
    4. Does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment; and
    5. Has psychological and social support during treatment; and
    6. Demonstrates knowledge and understanding of the expected outcomes of GnRH analog treatment.

Not Medically Necessary:

GnRH analogs are considered not medically necessary for adolescents with gender dysphoria when the criteria above are not met.

Policy: Treatment of Gender Dysphoria

Youth Services:

 

Puberty suppressing hormones (e.g., Supprelin LA® [histrelin acetate], Vantas® [histerlin acetate], Lupron Depot® [leuprolide acetate for depot suspension], Viadur® [leuprolide acetate implant], Eligard® [(leuprolide acetate for injectable suspension], Zoladex® [goserelin acetate implant], Trelstar® [triptorelin pamoate for injectable suspension]) are considered medically necessary and, therefore, covered, when all of the following criteria are met:

  • The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed), in accordance with criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, [DSM-5].
  • The individual has reached at least Tanner Stage 2 of development.
  • Gender dysphoria emerged or worsened with the onset of puberty.

 

Policy: Treatment of Gender Dysphoria

Youth Services:

PUBERTY-SUPPRESSING HORMONES
Puberty suppressing hormones (e.g., Supprelin LA® [histrelin acetate], Vantas® [histerlin acetate], Lupron Depot® [leuprolide acetate for depot suspension], Viadur® [leuprolide acetate implant], Eligard® [(leuprolide acetate for injectable suspension], Zoladex® [goserelin acetate implant], Trelstar® [triptorelin pamoate for injectable suspension]) are considered medically necessary and, therefore, covered, when all of the following criteria are met:

  • The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed), in accordance with criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, [DSM-5].
  • The individual has reached at least Tanner Stage 2 of development.
  • Gender dysphoria emerged or worsened with the onset of puberty.
Policy: Gonadotropin Releasing Hormone Analogs (GnRH)

Youth Services:

VI. Gender Dysphoria in Adolescents


A. GnRH analogs may be approved for adolescents (greater than or equal to 10 years of age and less than 18 years of age) with gender dysphoria when all of the following criteria are met:

1. Fulfills the DSMV criteria for gender dysphoria; and
2. Has experienced puberty to at least Tanner stage 2; and
3. Has (early) pubertal changes that have resulted in an increase of their gender dysphoria; and
4. Does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment; and
5. Has psychological and social support during treatment; and
6. Demonstrates knowledge and understanding of the expected outcomes of GnRH analog treatment.

May NOT be approved:
GnRH analogs may NOT be approved for adolescents with gender dysphoria when the criteria above are not met.

Policy: Transgender Services

Youth Services:

Age at least 18 years (Note: age requirement will not be applied to mastectomy in Female-to-Male patients with documented provider determination of medical necessity of earlier intervention)

No age restriction on hormones, GnRH treatment recommended under Endocrine Society guidelines.

Policy: Gender Reassignment Surgery Policy

Youth Services:

There is no minimum age requirement listed for coverage.

Policy: Gonadotropin Releasing Hormone Analogs and Antagonists

Youth Services:

Has coverage criteria for Leuprolide acetate suspension for intramuscular depot administration in children (Lupron Depo-Ped) and Histrelin acetate subcutaneus implant (Vantas and Supprelin)

Policy: GnRH Gender Dysphoria

Youth Services:

Off Label Use: GnRH analogues can be used in the treatment of Gender Dysphoria (GD) and should only be started once a diagnosis of GD or transsexualism has been made per the DSM V or ICD-10 criteria (1).

For Gender Dysphoria (GD):

MUST HAVE ALL of the following:

  1. Prescribed by an endocrinologist or transgender specialist
  2. Patient has met the DSM V criteria for GD
Policy: Treatments for Gender Dysphoria

Youth Services:

Hormone Therapy for Adolescents: Endocrine Society Clinical Practice Guidelines for endocrine treatment of transsexual persons state that adolescents are eligible and ready for gonadotropin-releasing hormone (GnRH) therapy for suppression of puberty if they:

  1. Fulfill DSM IV-TR or ICD-10 criteria for gender identity disorder (GID) or transsexualism
  2. Have experienced puberty to at least Tanner stage 2
  3. Have (early) pubertal changes that have resulted in an increase of their gender dysphoria
  4. Do not suffer from psychiatric comorbidity that interferes with the diagnostic work-up or treatment
  5. Have adequate psychological and social support during treatment
  6. Demonstrate knowledge and understanding of the expected outcomes of GnRH analog treatment, cross-sex hormone treatment, and sex reassignment surgery, as well as the medical and the social risks and benefits of sex reassignment
Policy: Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indic…

Youth Services:

  1. GnRH analogs are considered medically necessary for adolescents with gender dysphoria when all of the following criteria are met: 
    1. Fulfills the DSM V criteria for gender dysphoria; and 
    2. Has experienced puberty to at least Tanner stage 2; and 
    3. Has (early) pubertal changes that have resulted in an increase of their gender dysphoria; and 
    4. Does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment; and 
    5. Has psychological and social support during treatment; and 
    6. Demonstrates knowledge and understanding of the expected outcomes of GnRH analog treatment.
Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Youth Services:

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

• Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);

• Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or

• Chest surgery for FtM individuals.

Policy: Treatment of Gender Dysphoria

Youth Services:

Gender reassignment surgery may be considered medically necessary when ALL of the following criteria are met:  Age of majority in a given country. Note: WPATH guidelines address age of majority in a given country. For the purposes of this guideline, the age of majority is age 18. However, this refers to chronological age not biological age. Where approval or denial of benefits is based solely on the age of the individual a case-by-case medical director review is necessary.

Policy: Transgender Services

Youth Services:

Puberty Blockers

Gonadotropin-releasing hormone (GnRH) analog treatment for gender non-conforming adolescents seeking to delay puberty is covered at the discretion of the treating provider*. GnRH analogs may be used to either allow patients more time for decision making purposes or as an initial step prior to further gender affirming services such as hormone replacement.

Treatment options include but are not limited to:

  • Lupron
  • Supprelin LA
  • Vantas
  • Triptodur (triptorelin).

Surgical Services for Adolescents

Members < 18 years of age will be considered on a case-by-case basis.

In addition to meeting all of the above criteria, providers requesting surgery for members < 18 will need to provide documentation supporting all of the following:

  • The member has been evaluated for safety
  • The member has adequate home support
  • The member has realistic expectations regarding the possibilities and limitations of surgery and a full understanding of the long-term consequences of surgical procedures,
  • The member has been assessed for any co-existing mental health concerns and is not requesting surgery as an acute response to puberty.
Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Youth Services:

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

• Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);

• Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or

• Chest surgery for FtM individuals.

Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Youth Services:

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

• Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);

• Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or

• Chest surgery for FtM individuals.

Policy: Gender Confirmation Surgery and Hormone Therapy

Youth Services:

For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is (Note: for those candidates requesting female to male surgery see item 4. below): For candidates requesting female to male surgery only: a. When the initial requested surgery is solely a mastectomy, the treating physician may indicate that no hormonal treatment (as described in criteria 3. above) is required prior to performance of the mastectomy. In this case, the 12 month requirement for hormonal treatment will be waived only when all other criteria contained in this policy and in the member’s health benefit plan are met.  

Gender confirmation surgery is rarely appropriate for patients under the age of 18. Requests for mastectomy for female to male transgender individuals age 17 or older may be considered only in exceptional circumstances on an individual consideration basis.

Criteria for Adolescents Entering Puberty

Adolescents, having reached puberty (tanner 2), and who have met eligibility and readiness criteria can be treated with GnRH analogues.

The definition of puberty is having reached Tanner stage 2/5 and/or having LH, estradiol levels or testosterone levels, within the pubertal range. These LH, estradiol and testosterone ranges are well-known and published and are broken down by biological male vs. biological female Tanner stage, and nocturnal and diurnal levels.

Adolescents are eligible for GnRH treatment, (for suppression of puberty) by these eligibility criteria: (same for adults)

  1. Have an established diagnosis for GID or transsexualism based on DSM V or ICD-10 criteria;
  2. Have experienced puberty to at least Tanner stage 2, which can be confirmed by pubertal levels of LH, estrogen or testosterone;
  3. Have experienced pubertal changes that resulted in an increase of their gender dysphoria;
  4. Do not suffer from psychiatric comorbidity (that interferes with the diagnostic work-up or treatment);
  5. Have adequate psychological and social support during treatment, to include having parental/guardian consent;
  6. Demonstrate knowledge and understanding of the expected outcomes of GnRH analogue treatment, cross-sex hormone treatment, and gender confirmation surgeries, as well as the medical and social risks and benefits of gender reassignment; and have been counseled regarding fertility options.
Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Youth Services:

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

• Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);

• Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or

• Chest surgery for FtM individuals.

Policy: Gender Reassignment Surgery for Gender Identity Disorder

Youth Services:

Initiation of feminizing/masculinizing hormone therapy, preferably for members under the age of 18 with parental or legal guardian consent, may be provided after a psychosocial assessment has been conducted and informed consent has been obtained by a health professional.

Policy: Gonadotropin-releasing Hormone Agonists

Youth Services:

Coverage for Lupron Depot®/Lupron Depot Ped® is provided for treatment of the following conditions:

  • Gender dysphoria
    • The diagnosis of gender dysphoria and the referral for hormone therapy have been made by a mental health professional in accordance with the WPATH criteria AND
    • The patient must be followed by an endocrinologist AND
    • If used for suppression of puberty, therapy should not be started earlier than Tanner stage 2
Policy: GnRH Agents

Youth Services:

Adolescents are eligible and ready for GnRH treatment if they:

  1. Fulfill DSM IV-TR or ICD-10 criteria for GID or transsexualism.
  2. Have experienced puberty to at least Tanner stage 2.
  3. Have (early) pubertal changes that have resulted in an increase of their gender dysphoria.
  4. Do not suffer from psychiatric comorbidity that interferes with the diagnostic work-up or treatment.
  5. Have adequate psychological and social support during treatment, AND
  6. Demonstrate knowledge and understanding of the expected outcomes of GnRH analog treatment, cross-sex hormone treatment, and sex reassignment surgery, as well as the medical and the social risks and benefits of sex reassignment.

Note: Readiness criteria for adolescents eligible for cross-sex hormone treatment are the same as those for adults.

Policy: Gender Reassignment Surgery

Youth Services:

The member is age 18* or older on the date of service; AND [*Note: Plan Medical Director review is required for gender reassignment surgery for a member less than age 18 on the date of service. Requests for surgical treatment will be reviewed based on the Plan’s Medically Necessary medical policy (policy number OCA 3.14) and the WPATH Standards of Care for Health and Transsexual, Transgender, and Gender-Nonconforming People, with review of the member’s clinical situation, including but not limited to the amount of time the adolescent member has been living in the desired gender role, treatment timeframe with hormone therapy, age of the member, and the requested intervention. Adolescent members may be eligible for interventions when adolescents and their parents (or guardian) make informed decisions about treatment, and the service is a covered benefit for the Plan member. Informed consent by a parent or guardian for treatment of an adolescent member may not apply if the adolescent member is emancipated at the time the service is rendered.]

...

When gender reassignment surgery is requested and is a covered benefit for a Plan member under the age of 18 on the date of service (as specified in the member’s applicable benefit document available at www.bmchp.org or at www.SeniorsGetMore.org for a Senior Care Options member), Plan Medical Director review is required. Requests for treatment will be reviewed individually by a Plan Medical Director based on the Plan’s Clinical Criteria policy, policy number OCA 3.201, and must meet ALL applicable Plan criteria for the requested procedure(s), as specified in the Medical Policy Statement section of this policy.

Policy: Transgender Services

Youth Services:

Age at least 18 years (Note: age requirement will not be applied to mastectomy in Female-to-Male patients with documented provider determination of medical necessity of earlier intervention)

Policy: Gender Reassignment Surgery for Gender Dysphoria

Youth Services:

Individual consideration may be given to individuals under 18 years old wishing to undergo female to male chest surgery (e.g., mastectomy) after one year of testosterone therapy and when all other criteria are met.

Policy: Gender Reassignment Services

Youth Services:

Hormone therapy for individuals under the age of 18: For those without a medical contraindication to hormonal therapy, authorization of 12 months of hormone therapy is considered medically necessary for young adolescents with a diagnosis of gender dysphoria who are prescribed hormone therapy when ALL of the following criteria are met:

  • Hormone therapy is prescribed for pubertal suppression for the treatment of gender dysphoria; and
  • The individual has reached at least Tanner stage 2 of puberty.

Refer to CVS Caremark Specialty Guideline Management: Lupron Depot-PED and WPATH criteria Section VI.