CurrentAlliance HealthPolicy 1A-14

Surgery for Ambiguous Genitalia (Clinical Coverage Policy)

This policy governs coverage of reconstructive surgery for ambiguous genitalia (intersex variations) for North Carolina Medicaid beneficiaries and outlines medical necessity, eligibility, and limitations that providers must follow.

Policy Summary

PayerAlliance Health (NC Medicaid)

PolicySurgery for Ambiguous Genitalia

Policy CodePolicy 1A-14

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior approval from the DHHS Utilization Review Contractor and submit supporting medical records demonstrating the beneficiary meets the policy criteria before performing surgery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MedicaidPayer program

Prior approvalAuthorization

<21 appliesEPSDT

Inpatient/Outpatient/OfficeAuthorized sites

1985Original effective

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Covered indications

Covered when ALL of the following general medical necessity criteria are met and one of the specific criteria is present:

General medical necessity: a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary's needs; b. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; c. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

Specific covered indications: a. congenital anomaly diagnosed before two years of age; OR b. at the development of pronounced secondary sex characteristics during puberty

Administrative coverage prerequisites

Covered when administrative and documentation requirements are met

Administrative and documentation requirements: Prior approval obtained; the prior approval request and all supporting health records submitted to the DHHS Utilization Review Contractor demonstrating the beneficiary meets the specific criteria in Subsection 3.2; medical records must confirm the anomaly was diagnosed before the age of two years or document emergence of significant secondary sexual characteristics during puberty; a comprehensive postoperative care plan from the attending surgeon(s) is provided.

Medicaid does not cover the procedure, product, or service when any of the following apply: the beneficiary does not meet the eligibility requirements listed in Section 2.0; the beneficiary does not meet the criteria listed in Section 3.0; the procedure, product, or service duplicates another provider's procedure, product, or service; or the procedure, product, or service is experimental, investigational, or part of a clinical trial.

Specific Criteria Not Covered by Medicaid: None Apply.

Procedures that are experimental, investigational, or part of a clinical trial are not considered medically necessary and are not covered under this policy.

There are no additional Medicaid‑specific 'not covered' criteria listed in this section of the policy.

Prior Authorization, Documentation, and Billing Actions

Documentation Required

Eligibility Verification and EPSDT Documentation

Verify the beneficiary's Medicaid eligibility at each service. When the beneficiary is under age 21, follow EPSDT documentation requirements and include EPSDT justification with prior authorization requests when applicable. See NCTracks Provider Claims and Billing Assistance Guide and the NC DHHS EPSDT provider page for details.

Verify eligibility at each visit
When beneficiary <21, include EPSDT documentation/justification with PA as applicable
NCTracks Provider Claims and Billing Assistance Guide: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html
EPSDT info: https://medicaid.ncdhhs.gov/

Prior Authorization

Conservative Treatment Requirement

Services must be individualized, medically necessary, and consistent with the beneficiary's diagnosis or symptoms. Prior to surgical intervention, no equally effective, more conservative, or less costly treatment should be available statewide.

Procedure must be individualized and not in excess of beneficiary needs
No equally effective, more conservative, or less costly treatment available statewide

Prior Authorization

Prior Authorization Required

Prior approval from the DHHS Utilization Review Contractor is required before performing surgery for Ambiguous Genitalia. Submit the prior approval request along with all supporting health records that demonstrate the beneficiary meets the policy criteria.

Submit prior approval to DHHS Utilization Review Contractor
Include completed prior approval request form and all supporting health records

Documentation Required

Required Documentation with Prior Approval

Include with the prior approval request all pertinent medical records that document diagnosis, chronology, and clinical necessity. For Ambiguous Genitalia, records must confirm diagnosis before age two OR emergence of significant secondary sexual characteristics during puberty. A comprehensive postoperative care plan from the attending surgeon(s) must also be provided.

Prior approval request plus all supporting health records
Document diagnosis age: before 2 years OR significant secondary sexual characteristics during puberty
Attach comprehensive postoperative care plan from attending surgeon(s)

Billing Rule

Procedure Code Reporting

Report the appropriate procedure code(s) that determine billing units. Accurate coding is required for correct billing and claims adjudication.

Report correct procedure code(s) to determine billing units
Ensure codes reflect the service performed to avoid claim denials or adjustments

Note

Site of Service Verification

Place of service is Inpatient and Outpatient Hospital, and Office. Verify any site-specific prior authorization or coverage requirements with the payer before scheduling the service.

Place of Service: Inpatient Hospital, Outpatient Hospital, Office
Verify site-specific prior authorization requirements with payer

Denial Risk

Denial Triggers

Claims may be denied if the beneficiary does not meet Section 2.0 eligibility requirements, does not meet Section 3.0 medical necessity criteria, the service duplicates another provider's service, the service is experimental/investigational, or required documentation (including prior approval) is missing.

Denial triggers: failure to meet Section 2.0 eligibility
Denial triggers: failure to meet Section 3.0 criteria (medical necessity)
Denial triggers: duplicate service from another provider
Denial triggers: service is experimental/investigational or part of a clinical trial
Denial triggers: missing required documentation or lack of prior approval

Billing Rule

Modifier Compliance

Provider(s) shall follow applicable modifier guidelines. Failure to apply required modifiers correctly may result in claim adjustments or denials.

Follow applicable modifier guidelines
Incorrect or missing modifiers may trigger adjustments or denials

Billing Rule

Reimbursement Billing

Provider(s) shall bill their usual and customary charges. Follow payer-specific reimbursement schedules where applicable; see the NC DHHS Medicaid rates for applicable fee schedules.

Bill usual and customary charges
Refer to NC Medicaid fee schedules: https://medicaid.ncdhhs.gov/

Key Definitions

Intersex — definition

TermIntersex

DefinitionAn umbrella term for people with one or more variations in sex characteristics that fall outside traditional conceptions of male or female bodies.

OnsetVariations may be apparent at birth or become noticeable later (e.g., during puberty).

Clinical relevanceMay require reconstructive surgery (Surgery for Ambiguous Genitalia) when medically necessary and meeting policy criteria.

EPSDT — Exception to Policy Limitations

TermEPSDT (Early and Periodic Screening, Diagnostic, and Treatment)

Policy roleException to policy limitations for Medicaid beneficiaries under 21; referenced in coverage requirements and limitations.

Provider actionConfirm EPSDT applicability when beneficiary is under 21 and follow EPSDT documentation requirements with prior approval submissions.

Documentation requirementMedical records with prior approval must confirm anomaly diagnosed before age two or emergence of significant secondary sexual characteristics during puberty, plus a comprehensive postoperative care plan.

ICD-10-CM	Use current ICD-10-CM codes to highest specificity that supports medical necessity (codes not listed in policy).
CPT/HCPCS	Use current CPT and HCPCS codes to the highest specificity; if none exist use appropriate unlisted procedure codes (specific codes not listed).

CPT unlisted	Follow CPT instructions for Unlisted Procedure or Service and Special Report.
HCPCS unlisted	Follow HCPCS instructions for Unlisted Procedure or Service and Special Report.

OpenPayer

Surgery for Ambiguous Genitalia (Clinical Coverage Policy)

Coverage Criteria and Medical Necessity

Coding, Modifiers, and Billing Units

Prior Authorization, Documentation, and Billing Actions

Background and Scope

Key Definitions