BlueCross and BlueShield of Montana Medical Policy/Codes
Gender Assignment Surgery (GAS) and Gender Reassignment Surgery (GRS) with Related Services
Chapter: Surgery: Procedures
Current Effective Date: November 26, 2013
Original Effective Date: November 26, 2013
Publish Date: August 26, 2013
Description

Gender assignment surgery (GAS), also known as genitoplasty, is the genital reconstruction as a result of ambiguous genitalia in those individuals for whom it was difficult to classify them as a  male or female infant. The extent of the ambiguity varies. In very rare instances, the physical appearance may be fully developed as the opposite of the genetic sex (e.g., a genetic male may have developed the appearance of a normal female). (1) To the lay person the determination of an infant’s sex can easily be identified as male or female, by virtue of outward genital anatomy, secondary sexual characteristics and behavior within their relevant cultural context. Arriving at a satisfactory scientific definition is more difficult as gender reflects the outcome of complex interactions occurring from the time of conception and extending throughout pre- and postnatal life. (2)

Intersex anomalies associated with ambiguous genitalia may result from major chromosomal abnormalities or from specific gene mutations as in congenital adrenal hyperplasia (CAH). (2) Typically, the ambiguous genitalia in genetic females (babies with two X chromosomes) include an enlarged clitoris that has the appearance of a small penis. The urethral opening can be anywhere along, above, or below the surface of the clitoris. The labia may be fused, resembling a scrotum. The infant may be thought to be a male with undescended testicles. Sometimes a lump of tissue is felt within the fused labia, further making it look like a scrotum with testicles. (3, 4)

In a genetic male (babies with one X and one Y chromosome), the ambiguous genitalia typically include a small penis (less than 2-3 centimeters or 0.8-1.2 inches) that may appear to be an enlarged clitoris (the clitoris of a newborn female is normally somewhat enlarged at birth). The urethral opening may be anywhere along, above, or below the penis; it can be placed as low as on the peritoneum, further making the infant appear to be female. There may be a small scrotum with any degree of separation, resembling labia. Undescended testicles commonly accompany ambiguous genitalia. (3, 4)

Disorders which include ambiguous genitalia, which are usually not life threatening, have serious and potentially lifelong consequences for the affected child and, depending on the underlying cause, are likely to entail surgery in childhood and in later life, for example endocrine replacement therapy in conjunction with steroid replacement for those with CAH. (1) Making a correct determination of gender is both important for treatment purposes, as well as the emotional well-being of the child. Some children born with ambiguous genitalia may have normal internal reproductive organs that allow them to live normal lives. However, others may experience health issues from an underlying cause of the disorder. A list of the most common causes is listed below:

  • Pseudohermaphroditism, the genitalia are of one sex, but some physical characteristics of the other sex are present.
  • True hermaphrodism, a very rare condition in which both ovarian and testicular tissue is present. The child may have parts of both male and female genitalia.
  • Mixed gonadal dysgenesis, an intersex condition in which there appears some male structures (gonads, testis), as well as a uterus, vagina, and fallopian tubes.
  • CAH, a potentially life threatening condition, has several forms, but the most common form causes the genetic female to appear male.
  • Chromosomal abnormalities, including Klinefelter’s syndrome (XXY) and Turner’s syndrome (XO).
  • Maternal ingestion of certain medications (including androgenic steroids) may cause a genetic female to look more male.Lack of production of specific hormones can cause the embryo to develop with a female body type regardless of genetic sex, such as the lack of testosterone cellular receptors. (1)

Gender reassignment surgery (GRS), also known as sex reassignment surgery; genital reconstruction surgery; sex affirmation surgery; sex realignment surgery; intersex surgery, or sex-change operation, is a term used for the culmination of a series of surgical procedures and treatments by which a person’s physical appearance and function(s) of the existing sexual characteristics are altered or even permanently transformed/changed to resemble or conform to that of the opposite sex. Other terms are used to describe these procedures, such as sex reconstruction surgery; gender confirmation surgery; feminizing genitoplasty or penectomy, orchidectomy and vaginoplasty are used for trans-women, with masculinizing genitoplasty or phalloplasty often used for trans-men. These procedures and services make up the treatment of individuals diagnosed with gender identity disorder or gender dysphoria in transsexual or transgender people. GRS may be performed on intersex people, often in infancy, without their consent. (1, 2, 5, 6, 7)

GRS has been clarified by the World Professional Association for Transgender Health (WPATH) (1), formerly known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA) (8), an international, multispecialty, professional association whose mission is to promote evidence-based care, education, research, advocacy, public policy, and respect for transgender health. In May 2010, WPATH urged the de-psychopathologization of gender nonconformity worldwide, by stating, “The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common culturally-diverse human phenomenon [that] should not be judged as inherently pathological or negative.” WPATH clarified the related procedures and services when an individual is considering surgical transformation from male-to-female (MtF) or female-to-male (FtM), as well as how the treatment differs for gender identity disorder, gender dysphoria, and transsexualism. (1)

Terminology in Relationship to Transgender Health

Terminology in the area of health care for transsexual, transgender, and gender nonconforming individuals is rapidly evolving; new terms are being introduced, and the definitions of existing terms are changing. Thus, there is often misunderstanding, debate, or disagreement about language in this field. Terms that may be unfamiliar or that have specific meanings in the “Standards of Care” (SOC) are defined below for the purpose of this document only. Others may adopt these definitions, but WPATH acknowledges that these terms may be defined differently in different cultures, communities, and contexts. (1)

  • Sex is assigned at birth as male or female, usually based on the appearance of the external genitalia. When the external genitalia are ambiguous, other components of sex (internal genitalia, chromosomal and hormonal sex) are considered in order to assign sex. For most people, gender identity and expression are consistent with their sex assigned at birth; for transsexual, transgender, and gender nonconforming individuals, gender identity or expression differ from their sex assigned at birth. (1)
  • Disorders of sex development are the congenital conditions in which the development of chromosomal, gonadal, or anatomic sex is atypical. Some people strongly object to the “disorder” label and instead view these conditions as a matter of diversity (1), preferring the terms intersex and intersexuality.
  • Genital phenotype is largely determined by androgenic stimulation of the external genitalia in embryonic and fetal life and depends on the presence of the appropriate receptors in the target tissues. (2)
  • Gonadal phenotype is defined by the internal genitalia and the external morphology and microanatomy of the gonads (testis or ovary). (2)
  • Gender identity is the intrinsic sense of knowing to which sex one belongs—that is the awareness that ‘I am female” (a girl or woman), or “I am male” (a boy or a man). Gender identity is the private experience of gender role and gender role is the public expression of gender identity. Gender role can be defined as everything one says and does, including sexual arousal, to indicate to others or to oneself the degree to which one is male or female. (1)
  • Gender role or expression are characteristics in personality, appearance, and behavior that in a given culture and historical period are designated as masculine or feminine (that is, more typical of the male or female social role). While most individuals present socially in clearly masculine or feminine gender roles, some people present in an alternative gender role such as genderqueer or specifically transgender. All people tend to incorporate both masculine and feminine characteristics in their gender expression in varying ways and to varying degrees. (1)
  • Gender dysphoria or gender identity disorder is characterized by strong persistent cross-gender identification or a discrepancy between with the continuous discomfort or distress about one’s anatomic sex (person’s sex assigned at birth) or, by a sense of inappropriateness in the gender role of that sex. (1, 2) This includes inappropriateness clinically causes impairment in social, occupational, or other important areas of functioning. (2)
  • Gender nonconforming is an adjective to describe individuals whose gender identity, role, or expression differs from what is normative for their assigned sex in a given culture and historical period or the individual differs from the cultural norms prescribed for people of a particular sex. (1)
  • Transgender describes a diverse group of individuals who cross or transcend culturally-defined categories of gender. The gender identity of transgender people differs to varying degrees from the sex they were assigned at birth.
  • Trans-men assume male gender identities or strive to present in more male gender roles.
  • Transsexualism is a gender identifying disorder in which the person manifests, with constant and persistent conviction, the desire to live as a member of the opposite sex and progressively takes steps to live in the opposite sex role full-time. These individuals who seek to change or who have changed their primary and/or secondary sex characteristics through feminizing or masculinizing medical interventions (hormones and/or surgery), typically accompanied by a permanent change in gender role. (2)
  • Transvestism or cross-dressing describes the individual clothing and adopting a gender role presentation that, in a given culture, is more typical of the other sex.
  • Trans-women strive for female identity.
  • Genderqueer is the identity label that may be used by individuals whose gender identity and/or role does not conform to a binary understanding of gender as limited to the categories of man or woman, male or female.
  • Internalized transphobia describes the discomfort with one’s own transgender feelings or identity as a result of internalizing society’s normative gender expectations.
  • Transition is the period of time when individuals change from the gender role associated with their sex assigned at birth to a different gender role. For many people, this involves learning how to live socially in another gender role; for others this means finding a gender role and expression that is most comfortable for them. Transition may or may not include feminization or masculinization of the body through hormones or other medical procedures. The nature and duration of transition is variable and individualized.
  • Female-to-Male (FtM) describes individuals assigned female at birth who are changing or who have changed their body and/or gender role from birth-assigned female to a more masculine body or role.
  • Male-to-Female (MtF) describes individuals assigned male at birth who are changing or who have changed their body and/or gender role from birth-assigned male to a more feminine body or role.
Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Blue Cross and Blue Shield of Montana (BCBSMT) may consider gender assignment surgery (GAS) for patients with ambiguous genitalia reconstructive surgery and may be considered medically necessary.  

BCBSMT considers gender reassignment surgery (GRS), also known as transsexual surgery, or sex reassignment surgery, not medically necessary.

SPECIAL CONTRACT or CERTIFICATE of COVERAGE INFORMATION for GENDER REASSIGNMENT SURGERY and RELATED SERVICES 

If the not medically necessary or cosmetic exclusion is not applicable to GRS, utilize the following criteria for benefit coverage of services included in GRS services.

The member’s contract or certificate of coverage must allow specifically for GRS AND the member must meet ALL selection criteria.

Therefore CAREFULLY REVIEW the member’s benefit plan, summary plan description or contract for GRS provisions. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

For an individual whose benefit certificate covers GRS, the individual being considered for surgery must meet ALL the following criteria. The individual must have:

  • Reached the age of at least 18 years; and
  • The capacity to make a fully informed decision and to consent for treatment; and
  • Been diagnosed with persistent, well-documented gender dysphoria; and
  • Lived continuously for at least 12 months in the gender role (real life experiences) that is consistent with the preferred gender, without periods of time returning the individual’s original gender; and
  • Completed at least 12 months of continuous hormonal sex reassignment therapy of either male-to-female (MtF) or female-to-male (FtM); and
  • Undergone a urological examination to identify and treat abnormalities of the genitourinary tract; and
  • Been an active participant in a recognized gender identity treatment program; and
  • Referrals for surgery from the individual’s qualified mental health professionals competent in the assessment and treatment of gender dysphoria, which include:
  1. One referral required for breast/chest surgery that is mastectomy, chest reconstruction, or breast augmentation; AND
  2. One independent referral required for genital surgery that is hysterectomy, salpingo-oophorectomy, orchiectomy, and/or other genital reconstructive procedures. 

NOTE regarding mental health services: If the first referral is from the individual’s psychotherapist, the second referral should be from a clinician who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both, for example if both are practicing within the same clinic or program, may be sent. Psychotherapy is not required for GRS except when the mental health professional's initial assessment recommends psychotherapy that specifies the goals of treatment, estimates its frequency and duration throughout the real life experience.

SPECIAL CONTRACT or CERTIFICATE of COVERAGE INFORMATION for GENDER REASSIGNMENT SURGERY and RELATED SERVICES

The following section addresses specific procedures and services that may be performed.

NOTE: Some benefit plans may specify coverage for individual components of GRS. Therefore CAREFULLY REVIEW the member’s benefit plan, summary plan description or contract for GRS provisions. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Male to Female (MtF) procedures that may be considered as part of the GRS when the benefit coverage allows services for GRS for an individual who has met the above selection criteria include:

  • Clitoroplasty,
  • Coloproctostomy,
  • Colovaginoplasty,
  • Labioplasty,
  • Orchiectomy,
  • Penectomy
  • Penile skin inversion,
  • Repair of introitus,
  • Vaginoplasty with construction of vagina with graft, and/or
  • Vulvoplasty.

Female to Male (FtM) procedures that may be considered as part of the GRS when the benefit coverage allows services for GRS for an individual who has met the above selection criteria include:

  • Hysterectomy,
  • Metoidioplasty,
  • Phalloplasty,
  • Placement of an implantable erectile prostheses,
  • Placement of testicular prostheses,
  • Salpingo-oophorectomy,
  • Scrotoplasty,
  • Subcutaneous mastectomy,
  • Vaginectomy, as known as colpectomy,
  • Urethroplasty and/or
  • Urethromeatoplasty.

The following procedures or services are considered cosmetic or not medically necessary when used to improve the gender specific appearance of an individual who is planning to undergo or has undergone GRS, including but not limited to:

  • Abdominoplasty;
  • Blepharoplasty;
  • Breast modification, including but not limited to enlargement, augmentation mammoplasty, mastopexy, implant insertion, and silicone injections;
  • Brow lift;
  • Cheek implants;
  • Chin or nose implants;
  • Collagen injections;
  • External penile prosthesis (vacuum erection devices);
  • Face lift;
  • Facial bone reconstruction/sculpturing/reduction, includes jaw shortening;
  • Forehead lift or conturing;
  • Hair removal or hair transplantation (electrolysis or hairplasty);
  • Laryngoplasty;
  • Lip reduction or lip enhancement;
  • Liposuction or body conturing;
  • Neck tightening;
  • Nipple or areola reconstruction;
  • Reduction thyroid chondroplasty or trachea shaving;
  • Redundant skin removal;
  • Rhinoplasty;
  • Skin resurfacing;
  • Testicular expanders;
  • Voice modification surgery; or
  • Voice (speech) therapy or voice lessons.

Additional gender specific preventive medicine services for GRS individuals who are planning to undergo or have undergone GRS:

  • Breast cancer screening for FtM individuals who have not yet had a mastectomy;
  • Cervical cancer screening for FtM individuals who have not yet had a hysterectomy with or without salpingo-oophorectomy; or
  • Prostate cancer screening for MtF individuals who have opted to retain their prostate.

NOTE:  Continuous hormone replacement therapy services may be included in the specific coverage components allowed by some benefit plans. Therefore CAREFULLY REVIEW the member’s benefit plan, summary plan description or contract for GRS provisions. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern. Continuous hormone replacement therapy may include the following services:

  • Hormone injections by the medical provider, such as during an office visit, and/or
  • Self-administered oral and injectables obtained from a pharmacy.

Laboratory testing to monitor continuous hormone therapy for GRS individuals who are planning to undergo or have undergone GRS.

NOTE: Psychotherapy services may be included in the specific coverage components allowed by some benefit plans. Therefore CAREFULLY REVIEW the member’s benefit plan, summary plan description or contract for GRS provisions. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, sperm, and testicular tissue from individuals who are planning to undergo or have undergone GRS, despite whether or not the individual has reproduced in the past, is considered not medically necessary.

Rationale

Gender Assignment Surgery (GAS)

The ability to diagnose infants born with intersex conditions has advanced rapidly in recent years. In most cases today, clinicians can promptly make an accurate diagnosis and counsel parents on therapeutic options. However, the paradigm of early gender assignment has been challenged by the results of clinical and basic science research, which show that gender identity development likely begins in utero. While the techniques of surgical genital reconstruction have been mastered, the understanding of the psychological and social implications of gender assignment is poor. (1, 2, 3)

Treatment of ambiguous genitalia is controversial. No one debates the need to treat underlying physiologic problems such as those associated with congenital adrenal hyperplasia (CAH) or tumors in the gonads. However treatment for ambiguous genitalia depends on the type of disorder, but will usually include corrective surgery to remove or create reproductive organs appropriate for the gender of the child. Treatment may also include hormone replacement therapy (HRT). Controversy revolves around issues of gender reassignment by the physician and family which may not correlate with gender preference by the patient in adulthood. (1, 2, 3, 4) 

Reilly and Woodhouse interviewed and examined 20 patients with the primary diagnosis of micropenis in infancy” and concluded, “[A] small penis does not preclude a normal male role and a micropenis or microphallus alone should not dictate a female gender reassignment in infancy.” More particularly, these doctors found that when parents “were well counseled about the diagnosis they reflected an attitude of concern but not anxiety about the problem, and they did not convey anxiety to their children. They were honest and explained problems to the child and encouraged normality in behavior. We believe that this is the attitude that allows these children to approach their peers with confidence. (2, 3, 4, 9)

From a medico-legal standpoint, the best approach to managing these cases is to provide parents with as much information as possible so that they can make informed decisions. Adequate counseling and support for parents is vital. The ideal management method is a team approach including neonatologists, geneticists, endocrinologists, surgeons, counselors, and ethicists. (2, 3, 10)

Gender Reassignment Surgery (GRS)

Gender reassignment surgery is controversial among the available literature and few long term studies can be located. These controversial differences are most apparent due to the far reaching and irreversible results of hormonal and/or surgical transformation and the high rate of serious complications of these procedures. (6)

Postoperative complications include infection, hemorrhage, urethral urinary incontinence, rectal fistula, vaginal stenosis, and erectile tissue around the urethral meatus. Serious postoperative incidents include request for reversal, hospitalization and suicide. The incidence of the number of events attributed to postoperative complications cannot be ascertained with confidence due to variability between the studies, and the high rates of losses to follow up. (2, 11) Case series give some indication on the frequency of these events, although there is great variation in the figures presented, and suicide rates range from 0% to 18%. This data should be interpreted with caution, as figures are derived from small studies in which there are no control groups, incomplete follow up and the possibility of bias in reporting. (12, 13, 14)

Thrombotic risk of estrogen therapy should be considered when estimating potential harms of gender reassignment interventions. (15)

New problems may emerge following reassignment surgery. Some individuals may need to come to terms with painful loss including jobs, families, partners, children and friends. Many are forced to move away from their familiar environments despite being confident in their new gender roles. Many individuals have difficulty with social adaptation and acceptance by other members of society. (17, 18)

The evidence to support gender reassignment surgery is limited in that most studies are non-controlled and have not collected data prospectively. In addition, they are hampered by losses to follow up and a lack of validated assessment measures. It has been noted that a number of transsexual people experience a successful outcome in terms of subjective well-being, cosmesis and sexual function. The magnitude of benefit and harm cannot be estimated accurately using current evidence. (16, 18)

2012 Update

A MedLine search of peer reviewed literature through October 2012 identified one cohort study in Sweden of 324 sex-reassigned persons (191 male-to-female [MtF] and 133 female-to-male [FtM]). (19) The objective of this long-term follow-up study was to estimate mortality, morbidity, and criminal rate after GRS from 1973-2003. Dhejne et al. reported the overall mortality for sex-reassigned person was higher during the follow-up than the random controls of the matched by birth year and birth sex. The deaths primarily were from suicide. The sex-reassigned persons had an increased risk of suicide attempts and psychiatric inpatient care. There was a higher risk of criminal convictions in the FtM compared to controls, but not in the MtF group. The results suggest that GRS may alleviate the gender dysphoria, but may not suffice as treatment for individuals’ transsexualism. GRS remains controversial. (19)

The lack of well-controlled, long term studies of the safety and effectiveness of the GRS procedures and related services to complete the transformation from one sex to another, along with the serious complications that may occur, would not change the coverage position of this medical policy. GRS remains as not medically necessary.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes
62.41, 62.7, 64.3, 64.43, 64.5, 64.97, 65.61, 65.63, 68.41-68.49, 68.51, 68.59, 70.4, 70.61, 71., 71.62, 302.50, 302.51, 302.52, 302.53, 302.6, 302.85,  752.7, 752.89, 758.81 
ICD-10 Codes

OVT, OVR, OW4, OVU

Procedural Codes: 11950, 11951, 11954, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 17380, 19301, 19303, 19304, 19316, 19318, 19324, 19325, 19340, 19342, 19350, 21120, 21121, 21122, 21123, 21125, 21127, 30400, 30410, 30420, 30430, 30435, 30450, 53430, 54125, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54520, 54660, 54690, 55175, 55180, 55970, 55980, 56625, 56800, 56805, 56810, 57106, 57107, 57110, 57111, 57291, 57292, 57295, 57296, 57335, 57426, 58150, 58180, 58260, 58262, 58275, 58280, 58285, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58661, 58720, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90845, 90846, 90847, 90849, 90853, 90857
References
  1. Standards of care for the health of transsexual, transgender, and gender nonconforming people. World Professional Association for Transgender Health (WPATH) (2012 July) (7)1-114. Available at http://www.wpath.org (accessed on 2012 October 15).
  2. Thomas, D.F.M. Gender assignment: background and current controversies. British Journal of Urology (2004) 93(Supplement 3):47-50.
  3. eMedicine.com – Hutcheson, Joel. Ambiguous genitalia and intersexuality (2004 May 26). Available at http://www.emedicine.com (accessed on 2005 October 19).
  4. NIH.gov – Ambiguous genitalia. National Library of Medicine: MedLine (2005 June 17). Available at http://www.nlh.nig.gov (accessed on 2005 October 19).
  5. Dixen, J.M., Maddever, H., et al. Psychosocial characteristics of applicants evaluated for surgical gender reassignment. Archives of Sexual Behavior (1984) 13(3):269-76.
  6. Pauly, I.B. Outcome of sex reassignment surgery for transsexuals. Australia and New Zealand Journal of Psychiatry (1981) 15; 45-51.
  7. Mate-Kole, C., and M. Freschi. Psychiatric aspects of sex reassignment surgery. British Journal of Hospital Medicine (1988 February) 39(2): 153-5.
  8. Standards of Care for Gender Identity Disorders, Sixth Version. The Harry Benjamin International Gender Dysphoria Association (2001 February):1-22. Available at <http://www.wpath.org> (accessed on 2012 October 15).
  9. Reilly, J.M., and C.R.J. Woodhouse. Small penis and the male sexual role. Journal of   Urology (1989) 142:569-71.
  10. Bradley, S.J., and K.J. Zucker. Gender identity disorder: A review of the past 10 years. J Am Academy of Child Adolescent Psychiatry. (1997)36(7):872-80.
  11. Hunt, D.D., and J.L. Hampson. Follow-up of 17 biologic male transsexuals after sex reassignment surgery. American Journal of Psychiatry (1980) 137:432-8.
  12. Bouman, F.G. Sex reassignment surgery in male to female transsexuals. Annals of Plastic Surgery (1988) 21:526-31.
  13. Lawrence, A. Transsexual surgery: its pros and cons. Essay: Institute for Advanced of Human Sexuality (2000). Available at www.jenellerose.com (accessed on 2005 July 26).
  14. Sobralske, M. Primary care needs of patients who have undergone gender reassignment. Journal of the American Academy of Nurse Practitioners (2005 April) 17(4):133-8.
  15. Meriggiola, M.C., Jannini, E.A., et al. Endocrine treatment of transsexual persons: An Endocrine Society Clinical Practice Guideline: Commentary from a European perspective. European Journal of Endocrinology. (2010) 162(5):831-3.
  16. Sorensen, T.A. A follow-up study of operated transsexual males. Acta Psychiatrica Scandinavica (1981) 63:486-503.
  17. Mayer-Bahlburg, H.F. Introduction:  gender dysphoria and gender change in persons with intersexuality. Archives of Sexual Behavior (2005 August) 34(4):371-3.
  18. Krege, S., Bex, A., et al. Male-to female transsexualism: a technique, results and long- term follow-up in 66 patients. Ingentaconnect (2001 September) 88(4):396-402.
  19. Dhejne, C., Lichtenstein, P., et al. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLOS One (2011) 6(2):e16885.
History
August 2013  New 2013 BCBSMT medical policy.  Gender assignment surgery (GAS) for patients with ambiguous genitalia is considered reconstructive surgery and may be considered medically necessary.  Gender reassignment surgery (GRS), also known as transsexual surgery, or sex reassignment surgery, is considered not medically necessary. 
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Gender Assignment Surgery (GAS) and Gender Reassignment Surgery (GRS) with Related Services