CurrentAmbetter NevadaPolicy HIM.CP.MP.395

Coverage for Gender-Affirming Procedures

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This policy describes how Ambetter Health Plans determine coverage for gender-affirming procedures under state-specific mandates and the Federal Marketplace Integrity and Affordability Final Rule. Coverage differs by state, age group, and whether health plan-adopted medical-necessity criteria apply; intersex individuals are not subject to these criteria.

Policy Summary

PayerAmbetter Nevada

PolicyCoverage for Gender-Affirming Procedures

Policy CodePolicy HIM.CP.MP.395

Change TypeNo material change

Effective DateN/A

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionFor Medicare members and enrollees, review all applicable Medicare National Coverage Determinations, Local Coverage Determinations, and Medicare Coverage Articles before applying this policy.

SourceLink

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CurrentAmbetter NevadaPolicy HIM.CP.MP.395

Coverage for Gender-Affirming Procedures

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Sign up for Ambetter Nevada Policy HIM.CP.MP.395 alerts

Get alerted when Policy HIM.CP.MP.395 changes without checking for updates manually.

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Policy Summary

PayerAmbetter Nevada

PolicyCoverage for Gender-Affirming Procedures

Policy CodePolicy HIM.CP.MP.395

Change TypeNo material change

Effective DateN/A

Last ReviewAug 1, 2026

Next Review DateN/A

SourceLink

Coverage Criteria

Non-benefit states

Gender-affirming care for adolescents and adults is not an essential health benefit and is not covered in the following states:

Applicable state: The member's applicable state is Alabama, Arkansas, Arizona, Florida, Georgia, Iowa, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Nebraska, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, or Texas.

Coverage is excluded for adolescents and adults.

New Hampshire age-specific coverage

New Hampshire has age-specific coverage treatment:

Adolescent care: The service is gender-affirming care for an adolescent in New Hampshire.

Not an essential health benefit and therefore not covered.

Adult care: The service is gender-affirming care for an adult in New Hampshire.

Review using health plan-adopted gender-affirming-care medical-necessity criteria; the state benefit mandate applies for adults/adult coverage.

Benefit-mandate states

Gender-affirming services in the following benefit-mandate states will be reviewed using health plan-adopted gender-affirming-care medical-necessity criteria:

Benefit-mandate state: The member's applicable state is California, Delaware, Illinois, Michigan, Nevada, New Jersey, New York, Pennsylvania, or Washington.

Apply the health plan-adopted gender-affirming-care medical-necessity criteria.

Texas detransition services

Detransition services are covered as a benefit in Texas:

Detransition service: The requested service is a detransition service and the benefit-mandated state is Texas.

Covered benefit.

Intersex individuals are not subject to the coverage criteria in this policy.

Procedures undertaken to treat a person with a medically verifiable disorder of sexual development are excluded from the definition of specified sex-trait modification procedures addressed by this policy.

Procedures undertaken for purposes other than attempting to align an individual's physical appearance or body with an asserted identity that differs from the individual's sex are excluded from the definition of specified sex-trait modification procedures addressed by this policy.

Coding

Gender identity diagnosis codesICD-10

F64.0	Transsexualism
F64.1	Dual role transvestism
F64.2	Gender identity disorder of childhood
F64.8	Other gender identity disorders
F64.9	Gender identity disorder, unspecified
Z87.890	Personal history of sex reassignment

HCPCS codes that may be considered part of gender-affirming surgeryHCPCS

A4280	Adhesive skin support attachment for use with external breast prosthesis, each
C1789	Prosthesis, breast (implantable)
C1813	Prosthesis, penile, inflatable
C2622	Prosthesis, penile, non-inflatable
J1000	Injection, depo-estradiol cypionate, up to 5 mg
J1071	Injection, testosterone cypionate, 1 mg
J1380	Injection, estradiol valerate, up to 10 mg
J1675	Injection, histrelin acetate, 10 mcg
J1950	Injection, leuprolide acetate (for depot suspension), per 3.75 mg
J1951	Injection, leuprolide acetate for depot suspension (Fensolvi), 0.25 mg

1–10 of 45

1/5

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

11950	Subcutaneous injection of filling material (eg, collagen); 1 cc or less
11951	Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc
11952	Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc
11954	Subcutaneous injection of filling material (eg, collagen); over 10.0 cc
11960	Insertion of tissue expander(s) for other than breast, including subsequent expansion
11980	Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)
11981	Insertion, drug-delivery implant (ie, bioresorbable, biodegradable, non-biodegradable)
11982	Removal, non-biodegradable drug delivery implant
11983	Removal with reinsertion, non-biodegradable drug delivery implant
14001	Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm

1–10 of 57

1/6

Gender-Affirming ProceduresCPT

15830	Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
15832	Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
15833	Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
15834	Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
15835	Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock
15836	Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
15837	Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand
15838	Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad
15839	Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area
15847	Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty), includes umbilical transposition and fascial plication; list separately in addition to code for primary procedure

1–10 of 124

1/13

CPT CodesCPT

82670	Estradiol; total
82681	Estradiol; free, direct measurement (eg, equilibrium dialysis)
84270	Sex hormone binding globulin (SHBG)
84402	Testosterone; free
84403	Testosterone; total
96372	Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

Provider Actions

Prior Authorization

Review Medicare coverage authorities

For Medicare members/enrollees, review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles before applying the criteria in this clinical policy.

Denial Risk

Check for non-covered states

Gender-affirming care for adolescents and adults is not an essential health benefit and therefore is not a covered benefit in the following states: Alabama, Arkansas, Arizona, Florida, Georgia, Iowa, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Nebraska, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, and Texas.

Denial Risk

Background

This policy addresses coverage for pharmaceutical and surgical interventions intended to align an individual's physical appearance or body with an asserted identity that differs from the individual's sex. The interventions may intentionally disrupt or suppress the normal development of natural biological functions, including primary or secondary sex-based traits, or intentionally alter, amputate, minimize, or destroy primary or secondary sex-based traits, including sexual and reproductive organs.

Definitions

Specified sex-trait modification procedures

DefinitionAny pharmaceutical or surgical intervention intended to align an individual's physical appearance or body with an asserted identity that differs from the individual's sex.

Developmental effectsMay intentionally disrupt or suppress the normal development of natural biological functions, including primary or secondary sex-based traits.

Physical alterationsMay intentionally alter physical appearance or body, including amputating, minimizing, or destroying primary or secondary sex-based traits such as sexual and reproductive organs.

Developmental-disorder exclusionDoes not include procedures undertaken to treat a person with a medically verifiable disorder of sexual development.

Purpose exclusionDoes not include procedures undertaken for purposes other than attempting to align an individual's physical appearance or body with an asserted identity that differs from the individual's sex.