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ModifiedAmbetter NevadaPolicy CP.MP.95

Clinical Policy: Gender-Affirming Procedures

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Defines medical necessity criteria, covered procedures, and coding implications for gender-affirming medical and surgical treatments (GAMST) when included in a member/enrollee's benefit plan for Ambetter Nevada.

Policy Summary

PayerAmbetter Nevada

PolicyClinical Policy: Gender-Affirming Procedures

Policy CodePolicy CP.MP.95

Change TypeCriteria updatedcoding expandedcosmetic-procedure language revised

Effective Date

Next Review Date

Key ActionSubmit prior authorization with supporting documentation demonstrating medical necessity per the policy (diagnosis, required assessments, and provider recommendation).

SourceLink

POLICY UPDATE CHANGES

Criteria updated to incorporate WPATH Standards of Care version 8 (SOC-8).

Updated verbiage in Criteria IV to state that procedures used solely to improve appearance and unrelated to gender expression are not medically necessary and removed the list of procedures considered cosmetic.

Added 19318 to the list of CPT codes that may be considered part of gender-affirming procedures.

SOC-8Standards referenced

12 monthsAdolescent hormone duration

6 monthsAdult hormone duration

18+CPT codes listed

AnnualReview cadence

Coverage and Medical Necessity Criteria

General medical necessity criteria for GAMST

Covered when ALL of the following are met

A. Diagnosis: Member/enrollee has gender dysphoria or gender incongruence as defined by marked and sustained incongruence between experienced/expressed gender and assigned gender, demonstrated by two or more indicators (e.g., incongruence with primary/secondary sex characteristics; strong desire to be rid of or to have the sex characteristics of the other gender; strong desire to be of, or to be treated as, the other gender; conviction of having feelings/reactions of the other gender) and associated impairment in social, occupational, or other important areas of functioning.

See section I.A.

B. General eligibility: Capacity to make a fully informed decision and consent for treatment; if significant medical or mental health concerns are present, they must be reasonably well controlled; other possible causes of apparent gender dysphoria/incongruence have been identified and excluded; a minimum of one written, signed recommendation for gender‑affirming medical and surgical treatment (GAMST) from a provider competent to assess and diagnose gender incongruence; and age‑specific assessment requirements have been met.

See section I.B.1-5.

Policy Summary

PayerAmbetter Nevada

PolicyClinical Policy: Gender-Affirming Procedures

Policy CodePolicy CP.MP.95

Change TypeCriteria updatedcoding expandedcosmetic-procedure language revised

Effective Date

Next Review Date

Key ActionSubmit prior authorization with supporting documentation demonstrating medical necessity per the policy (diagnosis, required assessments, and provider recommendation).

SourceLink

On This Page

Age‑specific pathway: For members ≥ 18 years: assessment by a provider experienced/qualified to assess gender incongruence who is licensed and holds at minimum a master's degree in a clinical field related to transgender health (or equivalent training and statutory regulation); documented assessment identifying conditions that could negatively affect GAMST outcomes, discussion of risks/benefits including reproductive effects and fertility preservation options; member remains stable on gender‑affirming hormone treatment (which may include at least six months of hormone therapy unless not desired or medically contraindicated). For members < 18 years: demonstrates emotional and cognitive maturity for informed consent/assent; has reached Tanner stage 2; informed discussion of reproductive effects and fertility preservation appropriate to pubertal stage; completion of a minimum of 12 months of gender‑affirming hormone therapy (or longer if required to achieve the desired surgical result) for many procedures unless not desired or medically contraindicated; and assessment by a qualified/licensed provider meeting educational/training requirements.

Procedure-specific medical necessity

Procedures considered medically necessary when above general criteria are met and additional procedure-specific requirements are satisfied

Procedures for <18: When general criteria are met, the following procedures may be medically necessary for members <18 when requested and clinically indicated: penectomy; urethroplasty; mammoplasty; mastectomy (with assessment for breast cancer risk factors); clitoroplasty; vulvoplasty; labiaplasty; vaginectomy; vulvectomy; scrotoplasty; and testicular prosthesis. Certain major procedures (breast augmentation, phalloplasty, metoidioplasty, vaginoplasty, gonadectomy including hysterectomy or orchiectomy) require completion of 12 months of gender‑affirming hormone therapy (or longer if needed to achieve the desired surgical result) unless hormone therapy is not desired or is medically contraindicated.

See section I.C.1.

Procedures for ≥18: When general criteria are met, the following procedures may be medically necessary for adults (≥18) when requested and clinically indicated: penectomy; urethroplasty; mammoplasty; mastectomy (with assessment for breast cancer risk factors); clitoroplasty; vulvoplasty; labiaplasty; vaginectomy; vulvectomy; scrotoplasty; testicular prosthesis; breast augmentation (with breast cancer risk assessment); phalloplasty; metoidioplasty; vaginoplasty; and gonadectomy (hysterectomy, salpingo‑oophorectomy, orchiectomy). At least six months of hormone therapy may be considered prior to some procedures as appropriate to the member's goals, unless hormone therapy is not desired or is medically contraindicated.

See section I.C.2.

Facial procedures: Gender‑affirming facial procedures are evaluated case‑by‑case and may be medically necessary when core criteria in sections I.A. and I.B. are met and the requested procedure intends to correct facial appearance that demonstrates significant variation from standards for the experienced gender; for members <18, 12 months of hormone therapy is required prior to facial surgery unless not desired or medically contraindicated.

See section II.

Revision procedures are medically necessary when required to address complications of a prior gender‑affirming procedure (e.g., wound dehiscence, fistula, chronic pain directly related to the surgery). Revision solely for cosmetic purposes is not medically necessary.

See section III.

General medical necessity criteria (SOC-8 aligned)

Policy states coverage is determined by meeting clinical criteria aligned with WPATH SOC-8; intersex individuals may be exempt from some criteria.

Integration of SOC‑8: Eligibility and requirement language has been updated to incorporate the World Professional Association for Transgender Health (WPATH) Standards of Care version 8; criteria for duration of gender dysphoria, age requirements, and duration of prior treatment such as hormone therapy have been aligned with SOC‑8. Intersex (disorder of sexual development) individuals are noted as not subject to the same criteria and may be exempt from some requirements.

See revision history and criteria updates.

Facial and cosmetic procedures policy

Facial procedures and cosmetic stance

Facial/appearance procedures: Procedures used solely to improve appearance and that are unrelated to gender expression are considered not medically necessary. Determinations about facial or other appearance‑related procedures should emphasize whether the requested intervention is intended to address characteristics that significantly differ from norms for the member's experienced gender and meet clinical criteria; the prior list of procedures characterized as cosmetic was removed and case‑level assessment is required.

See Criteria IV and revisions noting removal of the cosmetic procedures list.

Coding and Procedural Codes

CPT codes referenced (informational)CPT

11950-11954	Subcutaneous injection of filling material (eg, collagen) series
11960	Insertion of tissue expander(s) for other than breast, including subsequent expansion
11970	Replacement of tissue expander with permanent implant
14000-14041	Adjacent tissue transfer or rearrangement (various sites and sizes)
15100-15121	Split-thickness autograft (various sites and increments)
15200	Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less
15570,15574	Formation of direct or tubed pedicle with or without transfer
15600,15620	Delay of flap or sectioning of flap (division and inset)
15757-15783,15786-15793	Free flaps, dermabrasion, chemical peels, punch grafts and related procedures
15820-15839,15876-15879	Blepharoplasty, rhytidectomy, excision of excess skin, liposuction

1–10 of 18

1/2

Facial/nasal CPT codesCPT

21208	Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)
21209	Osteoplasty, facial bones; reduction
21210	Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
21270	Malar augmentation, prosthetic material
30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
30410	Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
30420	Rhinoplasty, primary; including major septal repair
30430	Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

Urethral and laryngeal CPT codesCPT

30435	Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
30450	Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)
31599	Unlisted procedure, larynx
31899	Unlisted procedure, trachea, bronchi
53410	Urethroplasty, 1-stage reconstruction of male anterior urethra
53415	Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra
53420	Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage
53425	Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage
53430	Urethroplasty reconstruction female urethra

Penile prosthesis and amputation CPT codesCPT

54125	Amputation of penis; complete
54400	Insertion of penile prosthesis; non-inflatable (semi-rigid)
54401	Insertion of penile prosthesis; inflatable (self-contained)
54405	Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir
54406	Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis
54408	Repair of component(s) of a multi-component, inflatable penile prosthesis
54410	Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session

Orchiectomy and related CPT codesCPT

54411	Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue
54415	Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis
54416	Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session
54417	Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue
54520	Orchiectomy, simple (including subcapsular) with or without testicular prosthesis, scrotal or inguinal approach
54660	Insertion testicular prosthesis (separate procedure)
54690	Laparoscopy, surgical; orchiectomy

Genital reconstruction and intersex CPT codesCPT

55175	Scrotoplasty; simple
55970	Intersex surgery; male to female
55980	Intersex surgery; female to male
56625	Vulvectomy simple; complete
56800	Plastic repair of introitus
56805	Clitoroplasty for intersex state
56810	Perineoplasty, repair of perineum, nonobstetrical (separate procedure)

Vaginectomy and vaginoplasty CPT codesCPT

57106	Vaginectomy, partial removal of vaginal wall
57107	Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy)
57110	Vaginectomy complete removal vaginal wall
57111	Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy)
57291	Construction artificial vagina; without graft
57292	Construction artificial vagina; with graft
57295	Revision (including removal) of prosthetic vaginal graft; vaginal approach
57296	Revision (including removal) of prosthetic vaginal graft; open abdominal approach
57335	Vaginoplasty for intersex state

Hysterectomy and related CPT codesCPT

57426	Revision (including removal) of prosthetic vaginal graft, laparoscopic approach
58150	Total abdominal hysterectomy (corpus and cervix) with or without removal of tube(s), with or without removal of ovary(s)
58260	Vaginal hysterectomy, for uterus 250 g or less
58262	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58263	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele
58267	Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control

Laparoscopic hysterectomy CPT codesCPT

58541	Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less
58542	Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58543	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g
58544	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58550	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less

Additional laparoscopic hysterectomy CPT codesCPT

58552	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58553	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g
58554	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58570	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
58571	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

Adnexal and oophorectomy CPT codesCPT

58572	Laparoscopy, surgical, with total hysterectomy for uterus greater than 250 g
58573	Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58661	Laparoscopy surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
58720	Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
58940	Oophorectomy, partial or total, unilateral or bilateral
58999	Unlisted procedure, female genital system (nonobstetrical)

Additional reconstructive/nerve CPT codesCPT

64856	Suture of major peripheral nerve, arm or leg, except sciatic; including transposition
64892	Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length
64896	Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; more than 4 cm length
67900	Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

Minimum hormone therapy duration — Adults and Adolescents

AdultsCommon minimum of at least 6 months of gender-affirming hormone therapy prior to surgery (may be considered as appropriate for the member's goals).

AdolescentsMinimum of 12 months of gender-affirming hormone therapy is required for many gender-affirming procedures unless hormone therapy is not desired or is medically contraindicated.

ExceptionsHormone therapy duration may be shorter or waived when hormone therapy is not desired or is medically contraindicated; requirements vary by procedure.

Tanner stage requirement for members <18

ThresholdFor members under 18 years, the member must have reached Tanner stage 2 prior to certain gender-affirming procedures.

Assessment contextTanner stage requirement applies as part of age-specific assessment and informed discussion of reproductive effects for adolescents.

Source guidanceRequirement is specified in the policy's adolescent eligibility criteria and linked to pubertal development considerations.

Hormone therapy duration for mastectomy in adolescents

Mastectomy in adolescentsThe policy notes that the 12-month hormone therapy requirement before mastectomy in adolescents should be considered on a case-by-case basis (i.e., not absolute).

Individualized decisionDecisions should account for the adolescent's goals and whether hormone therapy is desired or medically contraindicated.

DocumentationWhen deviating from the 12-month expectation, clinical rationale should be documented per the policy's eligibility and assessment requirements.

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization Expected

Prior authorization is generally expected per the Health Plan's administrative processes. Providers should submit prior authorization requests and include all required documentation supporting medical necessity for gender-affirming medical and surgical treatment (GAMST). Inclusion of a CPT code in informational code lists does not guarantee coverage; prior authorization confirms benefit eligibility and medical necessity before services are rendered.

Prior authorization requests must reference the applicable policy number (CP.MP.95) and include supporting clinical records.
Code lists provided in the policy are informational; always verify coverage via prior authorization.

Documentation Required

Eligibility Documentation Required

Documented evidence of gender dysphoria or gender incongruence and fulfillment of all eligibility criteria in Section I.B are required. Absence of required documentation (capacity, controlled comorbidities, exclusion of alternative causes, signed recommendation, hormone therapy where indicated, age-specific requirements such as Tanner stage or hormone duration) may result in denial of the request.

Include documentation of diagnosis consistent with Section I.A.
Provide evidence of capacity to consent and that medical/mental health conditions are reasonably well controlled.
Supply records demonstrating exclusion of other causes of gender incongruence.
Provide records verifying hormone therapy duration when required (e.g., ≥6 months for adults when applicable; ≥12 months for certain procedures in minors).

Documentation Required

Required Assessment and Recommendation

At minimum, one written, signed statement recommending gender-affirming medical and surgical treatment (GAMST) from a qualified provider is required. The statement must document the assessment elements specified in the policy: capacity to consent (including discussion of fertility effects), identification and management of comorbid conditions, discussion of risks/benefits, and reproductive options. For adults, documentation must also show stability on hormone therapy when applicable.

The recommendation must be signed and dated by the assessing provider.
Assessment must explicitly document informed consent elements, fertility discussion, and risk/benefit counseling.

Note

Provider Qualifications

Assessments for GAMST must be performed by appropriately licensed and qualified providers. For members ≥18 years, the assessor must be licensed by their statutory body and hold at minimum a master’s degree in a clinical field related to transgender health or have equivalent further clinical training and statutory regulation. Acceptable providers include mental health professionals, general medical practitioners, nurses, or other qualified clinicians experienced in transgender health.

Include the assessor’s credentials, licensure, and evidence of relevant experience or training in the submitted documentation.
If a provider with different but equivalent qualifications performs the assessment, include documentation of the equivalent training or experience.

Documentation Required

Documentation and Precedence

Providers should treat this clinical policy as a guide to medical necessity and ensure submitted documentation aligns with the coverage criteria and Health Plan administrative requirements. Coverage decisions remain subject to the member’s benefit contract, state and federal law, and plan-level procedures. Maintain complete clinical records and attach them to authorization requests to streamline review and to establish precedence for medical necessity.

Attach full clinical assessment notes, treatment history, hormone therapy records, and the signed GAMST recommendation to the authorization request.
Note that this policy does not guarantee payment; final coverage is determined per the member's benefits and applicable laws.

Key Definitions

Gender dysphoria / gender incongruence (definition)

Core definitionMarked and sustained incongruence between experienced/expressed gender and assigned gender is required to meet gender dysphoria/gender incongruence criteria.

Evidence requiredMust be indicated by two or more specific criteria (e.g., incongruence with primary/secondary sex characteristics; strong desire to be rid of or have characteristics of the other gender; strong desire to be treated as the other gender; conviction of typical feelings of the other gender; associated impairment in functioning).

Role in coverageDiagnosis of gender dysphoria/gender incongruence per this definition is a prerequisite for coverage when eligibility criteria are applied.

Intersex / disorder of sexual development — policy note

Policy noteIndividuals with a disorder of sexual development (intersex) are not required to meet all the same criteria specified for other transgender/gender-diverse individuals.

ExemptionsIntersex persons may be exempt from criteria such as duration of gender dysphoria, age requirements, and duration of prior treatment (e.g., hormone therapy) as noted in the policy revision log and criteria text.

SOC-8 integrationThe policy revision incorporated WPATH Standards of Care version 8 and explicitly notes that intersex individuals are not subject to the same criteria in section I.

Policy Revision History

11/14policy_developed_approved

Policy developed and specialist reviewed; policy developed and approved on 11/14 (initial entry in revision history).

03/21code_description_update

Descriptions for CPT codes (e.g., 11970, 19325) were revised and administrative language updates made (replaced 'member' with 'member/enrollee').

11/21code_added

CPT code 19318 was added to the list of CPT codes that may be considered part of gender-affirming procedures.

01/23criteria_update_soc8

Criteria updated to incorporate WPATH Standards of Care version 8 (SOC-8); background and references updated and intersex individuals noted as not subject to all criteria.

07/24annual_review

Annual review with minor rewording in criteria and background; references reviewed and updated.

07/25cosmetic_procedures_verbiage_updateLatest

Clinical Policy: Gender-Affirming Procedures

Sign up for Ambetter Nevada Policy CP.MP.95 alerts

Coverage and Medical Necessity Criteria

Coding and Procedural Codes

Provider Requirements, Authorization, and Documentation

Background and Rationale

Key Definitions

Policy Revision History