ModifiedAmbetter NevadaPolicy WA.CP.MP.95

Gender-Affirming Procedures

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This policy governs medical-necessity determinations for gender-affirming medical and surgical treatment, including gender-affirming surgeries, facial procedures, revisions, and detransition procedures, when the services are included under the member or enrollee's benefit plan. Criteria apply to members and enrollees with gender dysphoria or gender incongruence, with separate requirements based on age and procedure.

Policy Summary

PayerAmbetter Nevada

PolicyGender-Affirming Procedures

Policy CodePolicy WA.CP.MP.95

Change TypeModified

Effective DateOct 1, 2026

Last ReviewAug 1, 2026

Next Review DateNot scheduled

Key ActionDocument the member's eligibility, informed consent capacity, fertility counseling, applicable hormone therapy, and procedure-specific requirements.

SourceLink

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ModifiedAmbetter NevadaPolicy WA.CP.MP.95

Gender-Affirming Procedures

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Policy Summary

PayerAmbetter Nevada

PolicyGender-Affirming Procedures

Policy CodePolicy WA.CP.MP.95

Change TypeModified

Effective DateOct 1, 2026

Last ReviewAug 1, 2026

Next Review DateNot scheduled

Key ActionDocument the member's eligibility, informed consent capacity, fertility counseling, applicable hormone therapy, and procedure-specific requirements.

SourceLink

POLICY UPDATE CHANGES

The August 2026 annual review added hysterectomy as a new criterion under Criterion I.C.1.b.vi.

The August 2026 annual review updated examples of gonadectomy in Criteria I.C.1.b.v and I.C.2.p.

The August 2025 annual review clarified that procedures used solely to improve appearance and unrelated to gender expression are not medically necessary.

The September 2024 revision added tracheal shaves to the criteria and added a section addressing detransition procedures.

2+Required diagnostic indicators

18 yearsAdult eligibility threshold

12 monthsMinor hormone therapy

6 monthsAdult hormone therapy

Case-by-caseFacial procedure review

2Supporting diagnosis code groups

Medical Necessity and Eligibility

Gender Dysphoria or Gender Incongruence

Gender-affirming surgeries are medically necessary when the member/enrollee has gender dysphoria or gender incongruence meeting the following criteria and satisfies the applicable eligibility requirements.

ALL of the following

At least 2 of the following indicators
- Marked incongruence between the member/enrollee's experienced or expressed gender and primary and/or secondary sex characteristics.
- A strong desire to be rid of one's primary and/or secondary sex characteristics because of marked incongruence with the member/enrollee's experienced or expressed gender.
- A strong desire for the primary and/or secondary sex characteristics of another gender.
- A strong desire to be of another gender, or an alternative gender different from the member/enrollee's assigned gender.
- A strong desire to be treated as another gender, or an alternative gender different from the member/enrollee's assigned gender.
- A strong conviction that the member/enrollee has the typical feelings and reactions of another gender, or an alternative gender different from the member/enrollee's assigned gender.
The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Age-Specific Eligibility

All applicable general eligibility requirements must be met, including the age-specific requirements below.

General eligibility requirements

The member/enrollee has the capacity to make a fully informed decision, including awareness of potential effects of treatment on fertility, and to consent to treatment.
Significant medical or mental health concerns, if present, are reasonably well controlled.
Other possible causes of apparent gender dysphoria, gender incongruence, or gender diversity have been identified and excluded.
At least one written and signed statement recommends gender-affirming medical and surgical treatment (GAMST) from a health care provider competent to independently assess and diagnose gender incongruence.
ONE of the following age-specific pathways

Gender-Affirming Surgery

Gender-affirming surgeries are medically necessary when the diagnosis and eligibility criteria above are met and the requested procedure is included in the applicable age pathway.

Any of the following procedures

Members/enrollees younger than 18 years
- Procedure requested without the additional 12-month hormone requirement
  - Penectomy.
  - Urethroplasty.
  - Mammoplasty.
  - Mastectomy, with assessment for breast-cancer risk factors.

Facial Procedures

Gender-affirming facial procedures are considered for medical necessity on a case-by-case basis when the following criteria are met.

ALL of the following

The criteria in Section I, including diagnosis and applicable eligibility requirements, are met.
The requested procedure is intended to correct an existing facial appearance that demonstrates significant variation from the standard appearance for the member/enrollee's experienced gender.
Requested procedure is one of, but not limited to, the following categories
- Blepharoplasty.
- Face lift, mid-face lift, or brow lift.

Revisions and Detransition

Revision and detransition procedures are reviewed under the standards below.

ONE of the following review pathways

Revision procedures
- The revision is required to address complications of a prior gender-affirming procedure, including wound dehiscence, fistula, or chronic pain directly related to the surgery.
- Another request for a revision procedure is submitted for case-by-case medical-necessity review.
A detransition procedure involving gender-related hormone intervention, surgical intervention, or both is submitted for case-by-case medical-necessity review.

Gender-Affirming Procedure Criteria Update

The revision-related criteria remain structured around medical necessity for complications and case-by-case review of other revision requests.

Revision procedures for affirming gender are medically necessary when required to address complications of a prior gender-affirming procedure; other revision requests are considered for medical necessity on a case-by-case basis.

Procedures used solely to improve appearance and unrelated to gender expression are not medically necessary because they are considered cosmetic in nature.

Procedures used solely to improve appearance and unrelated to gender expression are not medically necessary.

Cosmetic-only procedures that are unrelated to gender expression are not covered as medically necessary under this policy.

Appearance-only procedures unrelated to gender expression are not medically necessary.

Applicable Procedure and Diagnosis Codes

CPT codes that may be considered part of gender-affirming surgeryCPT

11950-11954	Subcutaneous injection of filling material (e.g., collagen).
11960	Insertion of tissue expander(s) for other than breast, including subsequent expansion.
11970	Replacement of tissue expander with permanent implant.
14000	Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less.
14001	Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm.
14040	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less.
14041	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm.
15100	Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children.
15200	Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less.
15570	Formation of direct or tubed pedicle, with or without transfer; trunk.

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CPT codes that may be considered part of gender-affirming surgeryCPT

11950-11954	Subcutaneous injection of filling material (e.g., collagen)
11960	Insertion of tissue expander(s) for other than breast, including subsequent expansion
11970	Replacement of tissue expander with permanent implant
14000	Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
14001	Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
14040	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
14041	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
15100	Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children
15101	Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children
15120	Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less

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ICD-10-CM Diagnosis Codes that Support Coverage CriteriaICD-10Covered

F64.0-F64.9	Gender identity disorders
Z87.890	Personal history of sex reassignment

Gender dysphoria or gender incongruence indicators

Required indicatorsAt least 2 of 6 listed indicators of marked and sustained incongruence between experienced or expressed gender and assigned gender.

Clinical impactThe condition must be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Listed featuresFeatures include incongruence with sex characteristics, a desire to be rid of or have the other gender’s characteristics, a desire to be another or be treated as another gender, or a conviction of having the typical feelings and reactions of another gender.

Adult hormone therapy

Minimum durationAt least 6 months of gender-affirming hormone treatment for adults, or longer if required to achieve the desired surgical result.

Documentation and Review Considerations

Documentation Required

Core Eligibility Documentation

Before requesting gender-affirming medical or surgical treatment (GAMST), document that the member has capacity to make a fully informed decision and consent, including understanding potential effects on fertility. Document that significant medical or mental health concerns are reasonably well controlled, other possible causes of apparent gender dysphoria, gender incongruence, or gender diversity have been identified and excluded, and at least one signed written recommendation for GAMST has been provided by a qualified provider.

Document informed decision-making capacity and consent.
Document counseling regarding fertility effects and reproductive implications.
Document control of significant medical or mental health concerns.
Include at least one signed written provider statement recommending GAMST.

Documentation Required

Age-Specific Assessment Documentation

The assessment documentation must address the member's age-specific eligibility requirements and be completed by a provider experienced or qualified to assess gender dysphoria, incongruence, and diversity who is licensed, statutorily regulated, and has at least a master's degree in a related clinical field or equivalent further clinical training.

Policy Context

Gender-affirming treatment is individualized and may include changes in gender expression or role, hormone therapy, surgery affecting primary or secondary sex characteristics, psychotherapy, and other body-modification procedures. Gender dysphoria describes distress or discomfort related to a discrepancy between gender identity and sex assigned at birth or associated characteristics, while gender incongruence focuses on the person's experienced identity and any resulting need for gender-affirming treatment.

Key Terms

Gender identity

DefinitionA person’s deepest inner sense of being female or male.

DevelopmentFor many people, gender identity is established by two to three years of age.

Policy contextGender identity may differ from the sex assigned at birth and may be expressed through a person’s gender role or expression.

Gender nonconformity

DefinitionThe extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex.

Areas of differenceGender nonconformity may involve a person’s identity, social role, or outward expression.

Policy Summary

PayerAmbetter Nevada

PolicyGender-Affirming Procedures

Policy CodePolicy WA.CP.MP.95

Change TypeModified

Effective DateOct 1, 2026

Last ReviewAug 1, 2026

Next Review DateNot scheduled

Key ActionDocument the member's eligibility, informed consent capacity, fertility counseling, applicable hormone therapy, and procedure-specific requirements.

SourceLink

On This Page

Members/enrollees age 18 years or older

Assessment for GAMST is performed by a provider experienced in, or qualified to assess, the clinical aspects of gender dysphoria, incongruence, and diversity.
The assessing provider is licensed by the applicable statutory body and holds at least a master's degree in a clinical field related to transgender health, or equivalent further clinical training, and is statutorily regulated.
The documented assessment identifies mental or physical health conditions that could negatively affect the outcome of GAMST, with risks and benefits discussed.
The documented assessment notes the member/enrollee's capacity to understand the effects of GAMST on reproduction and includes discussion of reproductive options before GAMST begins.
The member/enrollee remains stable on gender-affirming hormone treatment, which may include at least 6 months of hormone treatment or longer if needed to achieve the desired surgical result, unless hormone therapy is not desired or is medically contraindicated.

Members/enrollees younger than 18 years

The member/enrollee demonstrates the emotional and cognitive maturity required to provide informed consent or assent for treatment.
The member/enrollee has reached Tanner stage 2.
The member/enrollee has been informed of the reproductive effects of GAMST, including potential loss of fertility and available fertility-preservation options, with discussion in the context of the adolescent's pubertal development.
The member/enrollee has completed at least 12 months of gender-affirming hormone therapy, or longer if required to achieve the desired surgical result, unless hormone therapy is not desired or is medically contraindicated.
Assessment for GAMST is performed by a provider experienced in, or qualified to assess, the clinical aspects of gender dysphoria, incongruence, and diversity.
The assessing provider is licensed by the applicable statutory body and holds at least a master's degree in a clinical field related to transgender health, or equivalent further clinical training, and is statutorily regulated.

Testicular prosthesis.

Procedure requested after hormone therapy

At least 12 months of hormone therapy has been administered, unless hormone therapy is not desired or is medically contraindicated.
ANY of the following
- Breast augmentation, with assessment for breast-cancer risk factors.
- Phalloplasty.
- Metoidioplasty.
- Vaginoplasty.
- Gonadectomy, including orchiectomy, oophorectomy, or salpingo-oophorectomy.
- Hysterectomy.

Members/enrollees age 18 years or older

ANY of the following
- Penectomy.
- Urethroplasty.
- Mammoplasty.
- Mastectomy, with assessment for breast-cancer risk factors.
- Clitoroplasty.
- Vulvoplasty.
- Labiaplasty.
- Vaginectomy.
- Vulvectomy.
- Scrotoplasty.
- Testicular prosthesis.
- Breast augmentation, with assessment for breast-cancer risk factors.
- Phalloplasty.
- Metoidioplasty.
- Vaginoplasty.
- Gonadectomy, including oophorectomy, salpingo-oophorectomy, or orchiectomy; at least 6 months of hormone therapy may be considered before the procedure, as appropriate to the member/enrollee's goals.
- Hysterectomy.

Facial implants or bone reconstruction.

Hair removal or electrolysis.

Drugs for hair loss or growth.

Hair transplantation or hairline advancement.

Prosthetic or filler substances to alter contour.

Thyroid chondroplasty.

Removal of redundant skin.

Upper-lip shortening or lip augmentation.

Chondrolaryngoplasty.

Voice modification surgery, therapy, or lessons.

For members/enrollees younger than 18 years, 12 months of hormone therapy is required before facial surgery as part of gender-affirming treatment, unless hormone therapy is not desired or is medically contraindicated.

StabilityThe member or enrollee must remain stable on the gender-affirming hormonal treatment regimen.

ExceptionsThe hormone-therapy requirement does not apply when hormone therapy is not desired or is medically contraindicated.

Minor hormone therapy

Minimum durationAt least 12 months of gender-affirming hormone therapy, or longer if required to achieve the desired surgical result.

Applicable proceduresThe requirement applies to specified procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment.

ExceptionsThe hormone-therapy requirement does not apply when hormone therapy is not desired or is medically contraindicated.

Pubertal development

Required stageThe member or enrollee must have reached Tanner stage 2.

Applicable populationThis requirement applies to members and enrollees under 18 years of age.

Eligibility pathwayTanner stage 2 is one of the required conditions in the minor eligibility pathway for gender-affirming treatment.

Members age 18 or older: Document assessment of mental and physical health conditions that could negatively affect the GAMST outcome, including discussion of risks and benefits; document capacity to understand effects on reproduction and discussion of reproductive options before GAMST; and document stability on gender-affirming hormone therapy, generally at least 6 months or longer if needed for the desired surgical result, unless hormones are not desired or are medically contraindicated.
Members younger than 18: Document emotional and cognitive maturity for informed consent/assent, attainment of Tanner stage 2, and counseling about reproductive effects—including potential loss of fertility—and fertility-preservation options in the context of pubertal development.
For members younger than 18, document at least 12 months of gender-affirming hormone therapy, or longer if needed for the desired surgical result, unless hormones are not desired or are medically contraindicated.
Retain the qualifying assessor's credentials, licensure, statutory regulation, relevant experience or qualifications, and master's-level clinical education or equivalent training.

Documentation Required

Procedure-Specific Documentation

Include procedure-specific documentation showing that the requested surgery meets the applicable age, hormone-therapy, and assessment requirements. Breast procedures and facial procedures require additional documentation before medical-necessity review.

For members younger than 18, document the applicable requested procedure and either the required eligibility pathway or, for breast augmentation, phalloplasty, metoidioplasty, vaginoplasty, gonadectomy, or hysterectomy, 12 months of hormone therapy unless not desired or medically contraindicated. For mastectomy or breast augmentation, document assessment of breast-cancer risk factors.
For members age 18 or older, eligible procedures include penectomy, urethroplasty, mammoplasty, mastectomy, clitoroplasty, vulvoplasty, labiaplasty, vaginectomy, vulvectomy, scrotoplasty, testicular prosthesis, breast augmentation, phalloplasty, metoidioplasty, vaginoplasty, gonadectomy, and hysterectomy; document breast-cancer risk-factor assessment for mastectomy and breast augmentation.
For facial procedures, document that Section I criteria are met and that the request is intended to correct facial appearance with significant variation from the standard appearance for the member's experienced gender. Facial requests are reviewed case by case; for members younger than 18, document 12 months of hormone therapy unless not desired or medically contraindicated.
Facial procedures may include blepharoplasty, face/mid-face/brow lift, facial implants or bone reconstruction, hair removal or electrolysis, hair-loss or hair-growth drugs, hair transplantation or hairline advancement, contour-altering prosthetic or filler substances, rhinoplasty, thyroid chondroplasty, redundant-skin removal, upper-lip shortening or augmentation, chondrolaryngoplasty, voice modification surgery/therapy/lessons, and tracheal shave.

Denial Risk

Cosmetic-Only Procedures

Procedures used solely to improve appearance and unrelated to gender expression are considered cosmetic and are not medically necessary under this policy.

Do not submit appearance-only requests as medically necessary gender-affirming procedures when they are unrelated to gender expression.

Denial Risk

Eligibility Criteria Not Met

Expect denial when the member does not have a documented diagnosis of gender dysphoria or gender incongruence meeting the policy criteria, when required eligibility criteria are not met, or when the submitted records do not establish the applicable documentation and procedure-specific requirements.

Document marked and sustained incongruence between experienced or expressed gender and assigned gender, shown by at least two specified manifestations, with clinically significant distress or impairment; intersex individuals are not subject to these criteria.
Denial risk applies when informed decision-making capacity or consent, fertility counseling, control of significant health or mental health concerns, exclusion of other possible causes, or the signed provider recommendation is absent or insufficient.
Denial risk applies when age-specific assessment, maturity, Tanner stage, hormone-therapy duration, reproductive counseling, assessor qualifications, or other required documentation is missing or not satisfied.
Denial risk applies when a breast-cancer risk-factor assessment is not documented for a requested mastectomy or breast augmentation, or when facial-procedure criteria and case-by-case supporting documentation are not established.
Requests solely intended to improve appearance and unrelated to gender expression are cosmetic and not medically necessary.

Gender nonconformity describes difference from cultural norms and, by itself, does not describe distress or discomfort.

Gender dysphoria

DefinitionDiscomfort or distress caused by a discrepancy between a person’s gender identity and sex assigned at birth.

Associated factorsThe discrepancy may also involve the associated gender role and primary or secondary sex characteristics.

Clinical focusThe focus is on distress or discomfort related to being transgender or gender diverse, rather than on the person’s gender identity itself.

Gender incongruence

DefinitionA condition focused on a transgender or gender-diverse person’s experienced identity and any need for gender-affirming treatment arising from that identity.

Primary focusGender incongruence centers on the person’s experienced identity.

Treatment connectionThe condition includes any resulting need for gender-affirming treatment.

GAMST

MeaningGAMST means gender-affirming medical and surgical treatment.

Use in the policyAt least one signed written recommendation for GAMST from a provider competent to independently assess and diagnose gender incongruence is required.

Treatment contextGender-affirming treatment may include hormone therapy, surgery affecting primary or secondary sex characteristics, changes in gender expression or role, and psychotherapy.