Prior Authorization: Eligibility Verification

Prior authorization required. Verify member eligibility and that all diagnostic criteria and policy requirements are met before submitting an authorization request.

• Prior authorization required for listed gender-affirming procedures and associated CPT codes.
• Authorization requests must document diagnosis of gender dysphoria/gender incongruence and meet the policy's eligibility criteria.

Prior Authorization Required for Listed CPT Codes

Prior authorization is required for the CPT codes listed in the policy. Include supporting clinical documentation with the authorization request to allow medical necessity determination.

• Submit requests for codes such as 21208, 21209, 21210, 21270, 30400–30435, 53410–53430, 54125, 54400–54417, 54520, 54660, 55175, 55970–55980, 56625, 56800–56810, 57106–57296, 57335, 58150, 58541–58554, 58661, 58720, 58940, 64856, 64892, 64896, 67900, and other listed CPTs in the policy.
• If a code is not listed, include operative reports and rationale to support medical necessity.

Hormone Therapy Prerequisite

Many procedures require a period of gender-affirming hormone therapy prior to surgery unless hormone therapy is not desired or is medically contraindicated. Confirm and document hormone therapy status and duration.

• Members ≥18: typically a minimum of 6 months of hormone therapy is required and member should be stable on their hormone regimen, unless hormones are not desired or contraindicated.
• Members <18: typically a minimum of 12 months of hormone therapy is required prior to many procedures (breast augmentation, phalloplasty, metoidioplasty, vaginoplasty, gonadectomy, facial surgery), unless not desired or medically contraindicated.

Prior Treatment Duration Considerations

Duration requirements may be applied with clinical flexibility, particularly for adolescents. Consider case‑by‑case assessment (e.g., mastectomy in adolescents) and document rationale when deviating from standard minimum durations.

• Policy allows case-by-case consideration for the 12-month hormone therapy requirement in adolescents.
• If shorter or longer hormone duration is requested, provide clinical justification and supporting documentation.

Required Clinical Documentation

Provide complete clinical documentation with the prior authorization. At minimum, include one signed written statement from a qualified provider and a documented assessment addressing mental and physical health concerns relevant to gender-affirming care.

• One written signed recommendation for gender-affirming medical and surgical treatment (GAMST) from a provider competent to assess and diagnose gender incongruence is required.
• Document assessment must identify any medical or mental health conditions that could negatively impact outcomes and evidence that such conditions are reasonably well controlled.
• Document discussion of reproductive effects and fertility preservation options prior to initiation of GAMST.

Required Clinical Documentation (High-level)

Documentation must be consistent with WPATH Standards of Care (SOC-8) and include providers who meet the policy's qualifications. Mental health provider characteristics and referral letter requirements must align with policy standards.

• Assessments should be performed by providers experienced or qualified in transgender health and statutorily licensed; for adults this typically includes providers with relevant clinical master's level training or equivalent.
• For minors, documentation must demonstrate emotional/cognitive maturity, Tanner stage ≥2, and meet the policy's informed consent requirements.
• Documentation consistent with WPATH SOC-8 is expected; prior authorization may be denied if documentation is incomplete or does not meet SOC-8-aligned criteria.

Cosmetic Exclusion

Procedures performed solely to improve appearance and unrelated to gender expression are not medically necessary and may be denied. When the requested procedure is primarily cosmetic, clearly document how it is integral to the member's gender-affirming treatment to support medical necessity.

• Cosmetic-only procedures unrelated to gender expression may be denied as not medically necessary.
• Provide clear clinical justification and documentation tying the requested procedure to treatment of gender dysphoria/gender incongruence when applicable.