PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY / PROCEDURE
Policy/Procedure Number: MCUP3125
Policy/Procedure Title: Gender Identity Disorder/Surgical Treatment
Lead Department: Health Services
☒External Policy
☐ Internal Policy
Next Review Date: 08/21/2015
Last Review Date: 08/21/2013
Original Date: 08/21/2013
Applies to:
☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Reviewing
Entities:
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☒ PAC
Approving
Entities:
☐ CEO
☐ COO
☐ CREDENTIALING
Approval Signature: Robert Moore, MD, MPH
☐ DEPT. DIRECTOR/OFFICER
Approval Date: 08/21/2013
I.
RELATED POLICIES:
A. MCUP3041 TAR Review Process
II.
IMPACTED DEPTS:
A. --
III.
DEFINITIONS:
A. Gender Identity Disorder (GID) is a formal diagnoses used by psychologists and physicians to describe
persons who experience significant dysphoria (discontent) with the sex they were assigned at birth and/or
the gender roles associated with that sex. This condition is also known as gender dysphoria. Affected
individuals are commonly referred to as Transgender.
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
To define the criteria and process in which Partnership HealthPlan of California (PHC) will provide benefits
for the surgical treatment of Gender Identity Disorder.
VI.
POLICY / PROCEDURE:
A. When reviewing a request for the surgical treatment of GID Partnership Health Plan of California
utilizes the criteria as outlined by the World Professional Association for Transgender Health (WPATH).
All requests will be reviewed by the Chief Medical Officer or Physician Designee.
B. Gender reassignment surgery is a covered benefit when the individual with GID is at least 18 years of
age, has the capacity for fully-informed consent, and the WPATH criteria for the surgery have been met.
C. The following surgical procedures are covered when WPATH criteria are met:
1. Mastectomy
2. Orchiectomy
3. Hysterectomy
4. Salpingo-oophorectomy
5. Ovariectomy
6. Genital Surgery (including placement of testicular prosthesis when indicated)
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Policy/Procedure Number: MCUP3125
Lead Department: Health Services
☒ External Policy
Policy/Procedure Title: Gender Identity Disorder/Surgical
Treatment
☐ Internal Policy
Next Review Date: 08/21/2015
Original Date: 08/21/2013
Last Review Date: 08/21/2013
☐ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
D. Augmentation mammoplasty for male-to-female individuals (MtF) is a covered benefit only when an
appropriate trial of hormone therapy has not resulted in breast enlargement.
E. The following surgeries are considered cosmetic in nature and are not covered PHC Benefits:
1. Reduction thyroid chondroplasty
2. Rhinoplasty
3. Facial bone reconstruction
4. Face lift, blepharoplasty
5. Voice modification surgery
6. Hair removal or transplant
7. Liposuction Augmentation
8. Mammoplasty is not a covered benefit for MtF individuals except as noted above.
F. Treatment Authorization Review (TAR)
1. TARs must be submitted prior to any surgical procedure referenced in section C.6. Requests
received will be forwarded to the Chief Medical Officer or Physician Designee for review to
determine if the member has met the standard of care requirements under the WPATH criteria
G. Claims Submission
1. Intersex surgery should not be requested or billed using CPT-4 code 55970 (intersex surgery; male
to female) or CPT-4 code 55980 (intersex surgery; female to male). Due to the serial nature of
surgery for the gender transition, CPT-4 coding should be specific for the procedures performed
during each operation.
VII.
REFERENCES:
A. N/A
VIII.
DISTRIBUTION:
A. PHC Department Directors
B. PHC Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:
X.
REVISION DATES:
PREVIOUSLY APPLIED TO:
*********************************
In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with
involvement from actively practicing health care providers and meets these provisions:


Consistent with sound clinical principles and processes
Evaluated and updated at least annually
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Policy/Procedure Number: MCUP3125
Lead Department: Health Services
☒ External Policy
Policy/Procedure Title: Gender Identity Disorder/Surgical
Treatment
☐ Internal Policy
Next Review Date: 08/21/2015
Original Date: 08/21/2013
Last Review Date: 08/21/2013
☐ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal

If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be
disclosed to the provider and/or enrollee upon request
The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar
illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits
covered under PHC.
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