Baylor Scott & White Health Plan Gender-Affirming Prior Auth

Coverage Criteria and Medical Necessity

Surgical Medical Necessity Criteria

BSWHP may consider gender-affirming surgery medically necessary when ALL of the following general criteria are met for each specific procedure (and any procedure-specific criteria):

General surgical eligibility: A letter of referral from a qualified mental health professional; Persistent, well-documented gender dysphoria; Capacity to make a fully informed decision and to consent for treatment; Age 18 years of age or older; No significant medical or mental health concerns are present OR, if present, they are reasonably well controlled; Procedure-specific criteria as listed for each surgery.

Procedure-specific hormonal therapy: For gonadectomy (hysterectomy and oophorectomy as appropriate) and other specified procedures, the member must complete six (6) continuous months of hormone therapy as appropriate to the member's gender goals unless medically contraindicated.6 continuous months

Real-life experience: Must complete six (6) months of living in a gender role that is congruent with their gender identity (real life experience).6 months

The policy identifies a set of procedures that Baylor Scott & White Health Plan considers cosmetic and therefore not covered for standard plans. Examples called out in the policy include chest surgery components such as fat grafting (alone or with implant-based feminization) and initial breast reconstruction including augmentation with implants, as well as a broader list of aesthetic procedures (facial, body contouring, and related reconstructive techniques) that the plan treats as cosmetic. Plan-specific coverage may vary; providers must check the member's plan documents (EOC/SPD) for exceptions or different benefit rules.

Texas Senate Bill 14 (SB 14) is incorporated in the policy and establishes statutory prohibitions affecting minors. The law precludes provision or coverage for procedures and treatments intended to transition a child’s biological sex, including explicit prohibitions on performing surgeries that would sterilize a child (for example, castration, vasectomy, hysterectomy, oophorectomy, orchiectomy, penectomy, phalloplasty, vaginoplasty), mastectomy of a minor, and the prescribing, providing, or administering of certain medications that induce transient or permanent infertility (for example, puberty suppression/blocking drugs and supraphysiologic cross‑sex hormone dosing). The child health plan may not provide coverage for services prohibited under SB 14.

Policy history documents show recurrent updates since inception in 2010. Notably, on 04/30/2015 a pharmacologic and consultation exclusion was added to the policy record. Subsequent history entries reference alignment with professional standards (WPATH) and the later inclusion of SB14 language prohibiting certain procedures and treatments for minors.

The policy provides specific examples of procedures considered cosmetic and therefore not medically necessary for standard plans. Examples include chest-related procedures such as fat grafting and initial implant-based reconstruction, and a list of facial and body aesthetic procedures (rhinoplasty, dermabrasion, rhytidectomy, various grafts and osteoplasties) that the plan classifies as cosmetic. For standard plans these procedures are treated as not medically necessary (NMN), though the policy notes some plans may offer coverage for selected procedures; providers must verify coverage by plan.

The policy history and related entries reference age- and procedure-specific prohibitions and NMN determinations recorded over time. These historical notes, including additions such as the 2015 pharmacologic/consultation exclusion and later incorporation of SB14 language, inform current NMN and exclusion decisions where age (minor versus adult) or specific procedures trigger noncoverage under the plan or by state mandate.

Coding and Clinical Preconditions

Covered CPT/HCPCS Codes (examples listed)mixedCovered

11960	Insertion of tissue expander(s) for other than breast; including subsequent expansion
11970	Replacement of tissue expander with permanent implant
11971	Removal of tissue expander without insertion of implant
14041	genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
14301	Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm
14302	Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm
15100	Split-thickness autograft; trunk, arms, legs; first 100 sq cm or less
15101	Split-thickness autograft; each additional 100 sq cm
15200	Full thickness graft; free, including direct closure of donor site, trunk; 20 sq cm or less
15201	Full thickness graft; free; each additional 20 sq cm

1–10 of 62

1/7

Codes associated with procedures viewed as cosmetic (may be not covered)mixedNot Covered

11950	Subcutaneous injection of filling material (eg, collagen); 1 CC or less
11951	Subcutaneous injection of filling material; 1.1 to 5.0 cc
11952	Subcutaneous injection of filling material; 5.1 to 10.0 cc
11954	Subcutaneous injection of filling material; over 10.0 cc
15780	Dermabrasion; total face
15781	Dermabrasion; segmental, face
15782	Dermabrasion; regional, other than face
15783	Dermabrasion; superficial, any site
15786	Abrasion; single lesion
15787	Abrasion; each additional 4 lesions or less

1–10 of 24

1/3

ICD-10 Diagnosis Codes (examples)ICD-10

F64.X	Gender identity disorders
Z87.890	Personal history of sex reassignment

Hormone therapy duration — 6 continuous months requirement

RequirementComplete six (6) continuous months of hormone therapy as appropriate to the member's gender goals (unless medically contraindicated)

Applies toGonadectomy (hysterectomy and oophorectomy as appropriate) and other specified procedures

ExceptionMay be waived if hormone therapy is medically contraindicated

Real-life experience duration — 6 months living in congruent gender role

RequirementMust complete six (6) months of living in a gender role that is congruent with their gender identity (real life experience)

Purpose

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization: Required. Lack of prior authorization may result in denial of payment. Providers must verify prior authorization requirements and obtain approval before delivering gender‑affirming services when required by the member's plan.

Prior authorization required per product rules and coverage criteria
Failure to obtain prior authorization may lead to claim denial or non‑payment

Prior Authorization

Prior authorization requirement — verify member coverage

Prior authorization requirements apply according to product rules and the member's Evidence of Coverage (EOC) / Summary Plan Description (SPD). Providers should verify coverage, benefit limitations, and whether specific services (medical vs pharmacy benefit) are covered under the member's plan before initiating treatment.

Applies per product rules and coverage criteria
Providers must confirm whether hormonal therapy drugs are covered as a pharmacy or medical benefit

Background

Gender dysphoria is defined in the policy as the distress or discomfort that arises from a discrepancy between a person’s gender identity and the sex assigned at birth; it is associated with significant distress or functional impairment. The clinical goals of gender‑affirming care—behavioral healthcare, hormone therapy, and reconstructive surgery—are to alleviate that distress by aligning anatomy and care with the individual’s gender identity. The policy treats such impairment as the clinical rationale for considering medically necessary interventions when the stated eligibility criteria are met.

Key Definitions

Gender dysphoria — definition (distress due to mismatch between gender identity and sex assigned at birth)

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

Associated impactAssociated with significant distress or impairment in social, school, or other important areas of functioning

Clinical manifestationMay include desire to live as a member of the opposite sex and progressive steps to live full-time in that role

Gender reassignment surgery — definition and examples (series of procedures to change anatomy to conform to identified gender)

DefinitionA series of procedures designed to change anatomy to conform to the gender the person identifies with (also called transsexual surgery, sex reassignment surgery, or intersex surgery)

Examples (male-to-female)

Policy Revision History

2010-12-06policy_created

Policy created (new policy).

2011-12-06reviewed

Policy reviewed.

2012-10-25reviewed