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represents the most complete genitoperineal transformation, it requires complex, staged procedures, the use of tissue from remote sites, and the risk of complications associated with urethral reconstruction and implantable prostheses. For these reasons, some individuals forego phalloplasty and choose metoidioplasty instead. For many transmen, the last surgical stage after phalloplasty includes placement of penile and testicular prostheses. The choice of implant can vary depending on phalloplasty technique, patient preference, and availability of implants. At this time, implant availability depends on regulatory approval from the J Sex Med 2017;14:852e856 Surgical Training in Gender Surgery 855 various agencies in individual countries or regions. In addition, development of implants designed for phalloplasty procedures is ongoing and could be helpful in improving implant fixation and retention. Recommended metrics are (i) flap failure, (ii) delayed wound healing, (iii) VTE, (iv) urethral stricture or fistula, (v) blood transfusion, (vi) hospital-acquired UTI, (vii) unplanned return to the OR, and (viii) revision rate. Genital Surgery: Metoidioplasty and Phalloplasty Recommended case volume is 25 procedures in a 2-year period. CONCLUSION Gender confirmation surgery represents a new frontier in surgery. As such, a structured educational initiative coupled with a mechanism to track, assess, and evaluate outcomes is required. These efforts require a comprehensive and ethical approach to transgender and gender nonconforming patients. Corresponding Author: Loren S. Schechter, MD, FACS, 9000 Waukegan Road, Suite 210, Morton Grove, IL 60053, USA; E-mail: lss@univplastics.com Conflicts of Interest: L.S. receives royalties from Elsevier Publishing. E.K. is a consultant for AMS, Coloplast, Astellas, and Allergan. Funding: None. STATEMENT OF AUTHORSHIP Category 1 (a) Conception and Design Loren S. Schechter; Stan Monstrey (b) Acquisition of Data Loren S. Schechter; Salvatore D’Arpa; Ervin Kocjancic; Stan Monstrey (c) Analysis and Interpretation of Data Loren S. Schechter; Salvatore D’Arpa; Ervin Kocjancic; Stan Monstrey Category 2 (a) Drafting the Article Loren S. Schechter; Salvatore D’Arpa; Stan Monstrey (b) Revising It for Intellectual Content Mimis N. Cohen; Ervin Kocjancic; Karel E.Y. Claes; Stan Monstrey Category 3 (a) Final Approval of the Completed Article Loren S. Schechter; Salvatore D’Arpa; Mimis N. Cohen; Ervin Kocjancic; Karel E.Y. Claes; Stan Monstrey REFERENCES 1. World Professional Association for Transgender Health Standards of Care. Available at: http://s3.amazonaws.com/amo_hub_content/ Association140/files/Standards%20of%20Care%20V7%20-% 202011%20WPATH%20(2)(1).pdf. Published 2012. Accessed July 1, 2016. 2. World Professional Association for Transgender Health Standards of Care. Available at: http://www.wpath.org/site_page.cfm?pk_ association_webpage_menu¼1347&pk_association_webpage¼3 910. Accessed November 1, 2016. 3. Leclère F, Casoli V, Weigert R. Vaginoplasty in male-to-female transsexual surgery: a training concept incorporating dissection room experience to optimize functional and cosmetic results. J Sex Med 2015;12:2074-2083. 4. Leclère FM, Casoli V, Baudet J, et al. Description of the Baudet surgical technique and introduction of a systematic method for t I. Indications, Limitations of Coverage and/or Medical Necessity The purpose of this National Coverage Determination is to implement the U.S. Department of Health and Human Services Departmental Appeals Board’s 2014 decision overturning NCD 140.3 (Transsexual Surgery). The U.S. Department of Health and Human Services Departmental Appeals Board (“DAB”) considered categories of evidence as outlined in the Medicare Integrity Program Manual § 13.7.1 when it determined that the previously extant prohibition on “transsexual surgery” in NCD 140.3 was unreasonable.1 Implementing a policy to provide access to Gender Reassignment Surgery is centered in improving population health outcomes among transgender Medicare beneficiaries. The Medicare Integrity Program Manual § 13.7.1 provides that NCDs should be based on published authoritative evidence and general acceptance by the medical community. Summarized, this means treatments should follow: · Evidence-based best practice derived from definitive studies such as meta-analyses, randomized clinical trials, or clinical evidence · Best practice as accepted by the medical community, as supported by sound medical evidence based on: o Scientific data or research studies published in peer-reviewed medical journals; o Consensus of expert medical opinion (i.e., recognized authorities in the field); or o Medical opinion derived from consultations with medical associations or other health care experts. The Integrity Manual further provides that “NCDs which challenge the standard of practice in a community and specify that an item or service is never reasonable and necessary shall be based on sufficient evidence to convincingly refute evidence presented in support of coverage.” As such, a categorical exclusion of any particular procedure must be based on current, patientcentered clinical evidence, and not based on individual opinion or anecdote. The Medicare Benefit Policy manual defines cosmetic surgical
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