CurrentArizona Complete HealthPolicy CP.MP.95

Clinical Policy: Gender-Affirming Procedures

Medical necessity criteria and coding guidance for gender-affirming medical and surgical treatments for members/enrollees when such services are included under the benefit plan.

Policy Summary

PayerArizona Complete Health

PolicyClinical Policy: Gender-Affirming Procedures

Policy CodePolicy CP.MP.95

Change TypeMinor/administrative (no material clinical changes)

Effective Date

Next Review Date

Key ActionObtain prior authorization with documentation showing diagnosis of gender dysphoria/incongruence and required eligibility criteria (including required assessments and hormone therapy duration as applicable).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~80+CPT codes listed

≥18 / <18Age-based criteria

6m / 12mHormone duration

WPATH SOC-8Standards referenced

Exemptions notedIntersex exception

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General eligibility for gender-affirming surgeries

Covered when ALL of the following are met

A. Diagnostic criteria: Diagnosed with gender dysphoria or gender incongruence as evidenced by marked and sustained incongruence and two or more specified features (e.g., marked incongruence with primary/secondary sex characteristics; strong desire to be rid of primary/secondary sex characteristics; strong desire for characteristics of the other gender; strong desire to be the other gender or to be treated as the other gender; conviction of typical feelings/reactions of the other gender; associated functional impairment).

see section I.A

B. Eligibility criteria: Capacity to make a fully informed decision (including awareness of potential effects on fertility); significant medical or mental health concerns reasonably well controlled; other possible causes of apparent gender dysphoria/gender incongruence identified and excluded; at least one written, signed statement recommending gender-affirming medical and surgical treatment (GAMST) from a competent provider.

see section I.B items 1-4

B.5 age-specific requirements

Adult pathway: Assessment for GAMST by a provider experienced in or qualified to assess clinical aspects of gender dysphoria/incongruence who is licensed and holds at minimum a master's degree (or equivalent further clinical training); documented assessment identifies mental/physical conditions that could affect outcome and includes discussion of reproductive effects and options; member remains stable on gender-affirming hormone regimen (which may include at least 6 months of hormone therapy unless hormone therapy is not desired or is medically contraindicated).
section I.B.5.a
Adolescent pathway: Demonstrates emotional and cognitive maturity for consent/assent; has reached Tanner stage 2; informed of reproductive effects of GAMST and fertility preservation options discussed in context of pubertal development; completed minimum 12 months of gender-affirming hormone therapy (or longer if required to achieve desired surgical result) unless hormone therapy is not desired or medically contraindicated; assessment performed by a provider qualified for adolescent GAMST (licensed with postgraduate degree or equivalent and relevant expertise).
section I.B.5.b

Procedure-specific: Requested surgical procedure must meet the additional listed criteria for the applicable age group and operation (see policy for procedure lists and any procedure-specific requirements, including cancer risk assessment where noted).

section I.C

Facial gender-affirming procedures

Covered when ALL of the following are met

Facial criteria: General diagnostic (I.A.) and eligibility (I.B.) criteria are met; the requested facial procedure is intended to correct an existing facial appearance that demonstrates significant variation from the member/enrollee's experienced gender; for members <18 years, 12 months of hormone therapy is required prior to facial surgery as part of gender-affirming treatment unless hormone therapy is not desired or is medically contraindicated.

section II

Revision procedures

Covered when ALL of the following are met

Revision for complications: Revision procedures are medically necessary when they are required to address complications of a prior gender-affirming procedure (for example: wound dehiscence, fistula, chronic pain directly related to the surgery).

section III

Primary policy criteria (high-level)

Criteria updated to incorporate WPATH Standards of Care version 8; intersex individuals are not subject to the same criteria.

Standards and evidence: Policy criteria are aligned with WPATH Standards of Care version 8 (SOC-8) and have been reviewed by internal and external specialists.

See revision history and references

Intersex exception: Individuals with a disorder of sexual development (intersex) are not required to meet identical duration of gender dysphoria, age requirements, or duration of prior treatments (such as hormone therapy) as specified elsewhere in this policy.

Policy note prior to criteria section

Facial/appearance-only procedures: Procedures used solely to improve appearance and that are unrelated to gender expression are not medically necessary and are excluded from coverage.

Appearance-only exclusion replaces prior cosmetic-procedure list

It is the policy of Arizona Complete Health that procedures performed solely to improve appearance and that are unrelated to an individual’s gender expression are not medically necessary. Such services are considered cosmetic and are excluded from coverage.

Procedures whose only purpose is to enhance or alter appearance and that do not address gender dysphoria or gender incongruence are not medically necessary. Claims for interventions performed solely for appearance improvement and unrelated to gender expression may be denied.

Any procedure described as cosmetic-only and not intended to treat or align physical characteristics with the member’s experienced gender will be considered not medically necessary and is excluded from coverage under this policy.

Revision surgeries requested for purely cosmetic reasons — that is, revisions not intended to correct a complication of a prior gender-affirming procedure and not related to gender expression — are classified as not medically necessary. Revisions that are required to address complications (for example, wound dehiscence, fistula, or chronic pain directly related to the original surgery) remain medically necessary when documentation supports the clinical need.

Coding and Procedure Codes

CPT codes referenced (partial list)CPT

11950	Subcutaneous injection of filling material (eg, collagen).
11951	Subcutaneous injection of filling material (eg, collagen).
11952	Subcutaneous injection of filling material (eg, collagen).
11953	Subcutaneous injection of filling material (eg, collagen).
11954	Subcutaneous injection of filling material (eg, 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.

CPT codes referenced (continued)CPT

17380	Electrolysis epilation, each 30 minutes.
19303	Mastectomy, simple, complete.
19325	Breast augmentation with implant.
21120	Genioplasty; augmentation (autograft, allograft, prosthetic material).
30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip.
53410	Urethroplasty, 1-stage reconstruction of male anterior urethra.
54125	Amputation of penis; complete.
54400	Insertion of penile prosthesis; non-inflatable (semi-rigid).

Facial and rhinoplasty CPT codesCPTCovered

21208	Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft).
21209	Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant).
21210	Osteoplasty, facial bones; reduction.
21270	Graft, bone; nasal, maxillary or malar areas (includes obtaining graft).
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).

Genitourinary, hysterectomy, vaginectomy, vaginoplasty, and related CPT codesCPTCovered

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.
53460	Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type procedure).

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Additional hysterectomy and laparoscopy CPT codesCPTCovered

58275	Vaginal hysterectomy, with total or partial vaginectomy.
58285	Vaginal hysterectomy, radical (Schauta type operation).
58290	Vaginal hysterectomy, for uterus greater than 250 g.
58291	Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).
58292	Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele.
58294	Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele.
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).

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Miscellaneous related CPT codesCPTCovered

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).
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).
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.

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Hormone therapy duration — adults vs adolescents

Adults (≥18)Member should remain stable on gender-affirming hormone regimen; stability may include at least 6 months of hormone therapy when appropriate unless hormone therapy is not desired or is medically contraindicated.

Adolescents (<18)Member must have completed a minimum of 12 months of gender-affirming hormone therapy for many procedures (including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery) unless hormone therapy is not desired or is medically contraindicated.

Procedure-specific considerationFor gonadectomy and some procedures, at least 6 months of hormone therapy may be considered prior to procedure as appropriate to the member/enrollee's goals.

Case-by-case adolescent exceptionsRequirement of 12 months of hormone therapy before mastectomy in adolescents should be considered on a case-by-case basis (policy revision note).

Tanner stage requirement for some adolescent interventions

Minimum Tanner stageAdolescents must have reached Tanner stage 2 for some interventions as part of eligibility for gender-affirming medical and surgical treatment.

Assessment contextTanner staging and pubertal development should be considered alongside informed discussion of reproductive effects and fertility preservation options for adolescents.

Provider expectationsAssessment for GAMST in individuals <18 should be completed by a provider with postgraduate-level training and expertise in child/adolescent mental health and gender identity development to evaluate Tanner stage and maturity.

Hormone therapy duration notes — policy references and adolescent considerations

Policy-referenced durationsPolicy requires stability on hormone regimen; adults may include at least 6 months of hormone therapy and adolescents a minimum of 12 months for many procedures unless not desired or contraindicated.

Adolescent mastectomy noteThe requirement of 12 months of hormone therapy before mastectomy in adolescents should be considered on a case-by-case basis per revision notes.

Procedure-specific flexibilitySome procedures (e.g., gonadectomy) may consider at least 6 months of hormone therapy prior to surgery as appropriate to the member's goals.

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

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

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.

Documentation Required

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.

Note

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.

Documentation Required

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.

Documentation Required

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.

Denial Risk

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.

Definitions and Qualified Providers

Gender dysphoria / gender incongruence — definition and characteristic features

DefinitionMarked and sustained incongruence between the member/enrollee's experienced/expressed gender and assigned gender.

Characteristic featuresIndicated by two or more features such as marked incongruence with primary/secondary sex characteristics, strong desire to be rid of those characteristics, strong desire for characteristics of the other gender, desire to be treated as the other gender, conviction of typical feelings of the other gender, or associated impairment in social/occupational functioning.

Clinical impactThe condition may cause distress or impairment and is the focus for considering gender-affirming treatment per policy and WPATH guidance.

Qualified assessor (adults) — provider qualifications and minimum education/experience

License and educationProvider must be licensed by their statutory body and hold, at minimum, a master's degree in a clinical field related to transgender health or equivalent further clinical training.

Relevant provider typesExamples include mental health professionals, general medical practitioners, nurses, or other qualified health care providers with experience assessing gender dysphoria/incongruence.

Core assessment abilitiesAble to assess capacity to consent, identify coexisting mental/physical health conditions that could affect outcomes, and discuss reproductive effects and options with the member/enrollee.

Qualified assessor (adolescents) — provider qualifications for adolescent care

License and educationProvider must be licensed by their statutory body and hold a postgraduate degree or equivalent in a clinical field relevant to adolescent care granted by a nationally accredited statutory institution.

Specialized expertiseProvider should have training and expertise in child and adolescent mental health, gender identity development, and capacity assessment for assent/consent; training in neurodevelopmental presentations or collaboration with experts when needed.

Care continuity and collaborationProvider should maintain an ongoing relationship with the adolescent and involve relevant disciplines and caregivers (unless harmful) to support decision-making throughout puberty suppression, hormonal treatment, and surgical care.

Intersex / disorder of sexual development — note that these individuals are not subject to same criteria

Policy exceptionIndividuals with a disorder of sexual development (intersex) are not subject to the same criteria for duration of gender dysphoria, age requirements, and duration of prior treatments such as hormone therapy.

ApplicationThe policy specifically notes that intersex individuals need different consideration and are exempted from identical criteria applied to others seeking GAMST.

Documentation implicationAssessments and eligibility decisions should account for differences in clinical needs and not require identical prior treatment durations or age-based thresholds for intersex members.

WPATH SOC-8 — reference to Standards of Care version 8 incorporated into policy

Referenced standardWorld Professional Association for Transgender Health Standards of Care, version 8 (WPATH SOC-8) is incorporated into and informs the policy criteria.

Policy alignmentCriteria were updated to incorporate SOC-8 and background updated to reflect SOC-8 revisions; references reviewed and updated accordingly.

Provider expectationsDocumentation and assessments are expected to be consistent with WPATH SOC-8 guidance (e.g., qualifications, informed consent, and treatment considerations).

OpenPayer

Clinical Policy: Gender-Affirming Procedures

Coverage Criteria for Gender-Affirming Treatments

Coding and Procedure Codes

Prior Authorization, Documentation, and Provider Requirements

Background and Context

Definitions and Qualified Providers