ModifiedAmbetter NevadaPolicy CP.MP.95

Clinical Policy: Gender-Affirming Procedures

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This policy governs medical necessity for gender-affirming medical and surgical treatment, including surgeries, facial procedures, revisions, detransition procedures, and related services when covered under the member’s benefit plan. Criteria vary by age, diagnosis, clinical assessment, treatment history, and procedure requested.

Policy Summary

PayerAmbetter Nevada

PolicyClinical Policy: Gender-Affirming Procedures

Policy CodePolicy CP.MP.95

Change TypeModified — July 2026 annual revision

Effective DateN/A

Last ReviewJul 1, 2026

Next Review DateN/A

Key ActionDocument the applicable age, hormone therapy history or contraindication/non-desire, provider qualifications, reproductive counseling, and required risk assessments for the requested procedure.

SourceLink

POLICY UPDATE CHANGES

The July 2026 annual revision added hysterectomy as a criterion under section I.C.1.b.vi.

The July 2026 annual revision updated criterion I.C.1.b. to address achieving the desired surgical result.

The July 2026 annual revision updated examples of gonadectomy in criteria I.C.1.b.v. and I.C.2.p.

Hysterectomy was added as a new criterion under sections I.C.1.b.vi and I.C.2.q.

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ModifiedAmbetter NevadaPolicy CP.MP.95

Clinical Policy: Gender-Affirming Procedures

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

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Policy Summary

PayerAmbetter Nevada

PolicyClinical Policy: Gender-Affirming Procedures

Policy CodePolicy CP.MP.95

Change TypeModified — July 2026 annual revision

Effective DateN/A

Last ReviewJul 1, 2026

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

The July 2026 annual revision added hysterectomy as a criterion under section I.C.1.b.vi.

The July 2026 annual revision updated criterion I.C.1.b. to address achieving the desired surgical result.

The July 2026 annual revision updated examples of gonadectomy in criteria I.C.1.b.v. and I.C.2.p.

Hysterectomy was added as a new criterion under sections I.C.1.b.vi and I.C.2.q.

2+Gender dysphoria or gender incongruence indicators required

≥18Adult eligibility pathway

<18Adolescent eligibility pathway

6 monthsAdult hormone therapy period when applicable

12 monthsAdolescent hormone therapy period when applicable

SOC-8WPATH Standards of Care version

Medical Necessity and Eligibility

Gender dysphoria or gender incongruence

Gender-affirming surgery is medically necessary when the member has gender dysphoria or gender incongruence demonstrated by the following criterion:

Required diagnostic indicators: There is marked and sustained incongruence between the member's experienced or expressed gender and assigned gender, indicated by at least two of the following: marked incongruence with primary or secondary sex characteristics; a strong desire to be rid of those characteristics; a strong desire for the other gender's characteristics; a strong desire to be another gender or alternative gender different from the assigned gender; a strong desire to be treated as another gender or alternative gender; a strong conviction of having the typical feelings and reactions of another gender or alternative gender; or associated impairment in social, occupational, or other important areas of functioning.At least 2 manifestations

Facial procedures

Facial procedures are considered for medical necessity on a case-by-case basis when all of the following are met.

Gender-affirming facial procedures

The gender dysphoria or gender incongruence criteria and eligibility criteria are met.
The requested procedure is intended to correct an existing facial appearance that demonstrates significant variation from the standard appearance for the experienced gender.
For members younger than 18 years, required hormone therapy has been completed before facial surgery.12 months
Hormone therapy is not required when it is not desired or is medically contraindicated.
Possible procedure category: The requested service is one of the listed categories: blepharoplasty; face lift, mid-face lift, or brow lift; 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; rhinoplasty; thyroid chondroplasty; removal of redundant skin; upper-lip shortening or lip augmentation; chondrolaryngoplasty; or voice-modification surgery, therapy, or lessons.

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

A procedure is not medically necessary when it is performed solely to improve appearance and is unrelated to the member’s gender expression.

Codes and Treatment Parameters

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, or part thereof
15120	Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children

1–10 of 32

1/4

CPT CodesCPT

15787	Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure).
15788	Chemical peel, facial; epidermal.
15789	Chemical peel, facial; dermal.
15792	Chemical peel, nonfacial; epidermal.
15793	Chemical peel, nonfacial; dermal.
15820-15823	Blepharoplasty.
15824	Rhytidectomy; forehead.
15825	Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap).
15826	Rhytidectomy; glabellar frown lines.
15828	Rhytidectomy; cheek, chin, and neck.

1–10 of 101

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Adult hormone therapy

Minimum durationAt least six months of gender-affirming hormone treatment

Extended durationLonger than six months if required to achieve the desired surgical result

ExceptionsHormone therapy may be omitted when it is not desired or is medically contraindicated

Adolescent hormone therapy

Minimum durationA minimum of 12 months of gender-affirming hormone therapy

Extended durationLonger than 12 months if required to achieve the desired surgical result

Documentation and Coverage Risks

Documentation Required

Document Informed Consent and Decision-Making Capacity

Document that the member/enrollee has the capacity to make a fully informed decision and consent to treatment, including awareness of potential treatment effects on fertility. Record reproductive-effects counseling and available fertility-preservation options before treatment, as applicable.

For members/enrollees younger than 18, document the emotional and cognitive maturity required for informed consent or assent.
Document discussion of the potential loss of fertility and reproductive options in the context of the adolescent’s pubertal development.

Documentation Required

Document Medical and Mental Health Assessment

Document that significant medical or mental health concerns are reasonably well controlled and that other possible causes of apparent gender dysphoria, gender incongruence, or gender diversity have been identified and excluded.

Identify physical and mental health conditions that could negatively affect the outcome of gender-affirming medical and surgical treatment.

Policy Background

Gender dysphoria describes distress or discomfort associated with a discrepancy between a person’s gender identity and sex assigned at birth, including related gender roles or primary and secondary sex characteristics. The policy recognizes that gender-affirming treatment is individualized and may include changes in gender expression, hormone therapy, surgery or body modification, and psychotherapy; not every person requires every intervention.

This policy establishes medical-necessity criteria for gender-affirming medical and surgical treatment. Coverage consideration depends on the applicable diagnosis or gender incongruence criteria, clinical assessment, eligibility requirements, treatment history, age-specific requirements, and procedure requested.

Key Terms

Gender identity

DefinitionA person's deepest inner sense of being female or male

Typical developmentFor many people, gender identity is established by age two to three years

Policy contextGender identity is distinct from gender dysphoria, which concerns distress or discomfort related to a discrepancy with sex assigned at birth

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 includedGender nonconformity may involve a person's identity, role, or expression

Policy Summary

PayerAmbetter Nevada

PolicyClinical Policy: Gender-Affirming Procedures

Policy CodePolicy CP.MP.95

Change TypeModified — July 2026 annual revision

Effective DateN/A

Last ReviewJul 1, 2026

Next Review DateN/A

SourceLink

On This Page

ExceptionsHormone therapy may be omitted when it is not desired or is medically contraindicated

Applicable proceduresIncludes breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment

Tanner stage

Required developmental stageTanner stage 2

Applicable populationMembers and enrollees younger than 18 years

Related requirementThe member must demonstrate the emotional and cognitive maturity required to provide informed consent or assent for treatment

Document discussion of treatment risks and benefits.

Documentation Required

Obtain a Signed Provider Recommendation

Include at least one written, signed recommendation for gender-affirming medical and surgical treatment from a healthcare provider competent to independently assess and diagnose gender incongruence.

The recommendation must be signed and written.
The recommending provider must be qualified to independently assess and diagnose gender incongruence.

Documentation Required

Submit Procedure-Specific Supporting Records

Submit procedure-specific records establishing the member/enrollee’s age, applicable hormone-treatment history or documented exception, assessment, provider qualifications, and the criteria for the requested procedure. Adult and adolescent requirements differ and must be documented separately.

For members/enrollees age 18 or older, document an assessment by a provider experienced or qualified in gender dysphoria, incongruence, and diversity who is statutorily licensed or regulated and has at least a master’s degree in a relevant clinical field or equivalent further clinical training.
For members/enrollees age 18 or older, document stability on gender-affirming hormone treatment, generally including at least six months or longer when needed for the desired surgical result, unless hormones are not desired or are medically contraindicated.
For members/enrollees younger than 18, document Tanner stage 2, the required emotional and cognitive maturity, and at least 12 months of gender-affirming hormone therapy when required for the desired surgical result, unless hormones are not desired or are medically contraindicated.
For members/enrollees younger than 18, document the qualified provider assessment and applicable procedure-specific requirements, including breast-cancer risk assessment for mastectomy or breast augmentation when applicable.
Confirm that the requested surgery is one of the policy-listed procedures, such as penectomy, urethroplasty, mammoplasty, mastectomy, breast augmentation, phalloplasty, metoidioplasty, vaginoplasty, gonadectomy, hysterectomy, or other listed procedures applicable to the member’s age.
For gender-affirming facial procedures, document that Sections I.A and I.B criteria are met and that the procedure addresses facial appearance demonstrating significant variation from standard appearance for the experienced gender. For members/enrollees younger than 18, document 12 months of hormone therapy before facial surgery unless hormones are not desired or are medically contraindicated.

Documentation Required

Document Complications for Revision Procedures

For a revision procedure, document that it is medically necessary to address a complication of a prior gender-affirming procedure rather than a routine or cosmetic revision.

Identify the prior gender-affirming procedure and describe the resulting complication.
Document the medical need for revision, such as wound dehiscence, fistula, or chronic pain directly related to the prior surgery.

Denial Risk

Cosmetic-Only Procedures Are Not Medically Necessary

Flag procedures used solely to improve appearance and unrelated to gender expression as cosmetic and not medically necessary under this policy.

Document the procedure’s gender-affirming purpose when coverage is requested.
Appearance-only services unrelated to gender expression are not medically necessary.

Denial Risk

Surface Eligibility and Coverage Risks

Coverage is at risk when the diagnostic, eligibility, provider-assessment, consent, hormone-treatment, age, or procedure-specific requirements are not met or cannot be supported in the record.

The policy requires gender dysphoria or gender incongruence criteria, including marked and sustained incongruence supported by at least two specified features.
Deny or anticipate denial when informed consent capacity, fertility-effects counseling, control of significant medical or mental health concerns, exclusion of other causes, or the signed provider recommendation is missing.
Deny or anticipate denial when required provider qualifications, age-specific criteria, hormone-treatment history or exception, Tanner stage, breast-cancer risk assessment, or requested-procedure criteria are not documented.
Facial procedures require case-by-case medical-necessity review and compliance with the policy’s facial-appearance criteria.
Revision procedures require documentation of a complication of a prior gender-affirming procedure and medical necessity for the revision.

The comparison is with cultural norms prescribed for people of a particular sex

Gender dysphoria

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

Associated characteristicsThe discrepancy may 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 individual's gender identity itself

Gender incongruence

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

Primary focusThe condition focuses on the person's experienced identity

Treatment connectionAny need for gender-affirming treatment arises from the person's experienced identity