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On June 29, 2014, the Centers for Medicare & Medicaid Services (CMS)
implemented the invalidation of National Coverage Determination (NCD) 140.3:
Transsexual Surgery. Therefore, reasonable and necessary gender reassignment
surgery may be covered for Independence Medicare Advantage HMO/POS and PPO
members.
Claims submission in 2015
For calendar year 2015, gender reassignment surgery claims for members
enrolled in Medicare Advantage HMO/POS and PPO products should be submitted to
the appropriate Medicare Administrative Contractor (MAC). The MAC will consider
whether gender reassignment surgery is reasonable and necessary for
Independence Medicare Advantage members. Please note the following:
- Independence will not be required to review or provide coverage
authorization/precertification for gender reassignment surgery during calendar
year 2015.
- Gender reassignment surgery claims should not be submitted directly to
Independence in 2015 for members enrolled in Medicare Advantage products.
- Gender reassignment surgery claims will not be processed by Independence in
2015.
Providers and facilities should contact the MAC to which they submit claims for
inquiries about coverage of gender reassignment surgery that will be performed
in 2015.
Policy changes in 2016
For calendar year 2016, gender reassignment surgery claims will be processed
by Independence. At that time, Independence will assume responsibility for
providing medical necessity review and precertification. Effective January
1, 2016, a coverage policy will be implemented to define medical necessity
criteria for gender reassignment surgery for members enrolled in Medicare
Advantage HMO/POS and PPO products.
If you have any questions, please contact your Network Coordinator.
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