Gender-Affirming Care — Coverage, Medical Necessity, Prior Authorization and Coding Guidance
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This policy governs coverage, medical necessity criteria, and prior authorization requirements for gender-affirming medical, behavioral, fertility preservation, and surgical services for transgender and gender diverse members of Blue Cross Blue Shield - Massachusetts.
Policy updated to clarify coverage for facial feminization procedures (e.g., orbital contouring) and specified monsplasty as non-covered.
Investigational indications were revised in the 1/2025 action.
Prior authorization requirements for outpatient services were clarified for different product lines, including that prior authorization is not required for surgically implanted puberty blockers and certain HCPCS codes.
Coverage and Medical Necessity Criteria
Medically Necessary Surgical Criteria
Gender-affirming surgeries are considered MEDICALLY NECESSARY when ALL criteria in Table 1 are met AND any additional procedure-specific criteria in Table 2 are met.
Referenced in Table 1
Procedure-specific criteria from Table 2
Non-surgical medical and supportive services
Medical treatments and supportive services coverage stance
Puberty blocker criteria referenced
Hormone therapy coverage note
Behavioral health and voice services coverage
Fertility preservation
Fertility preservation
Refer to medical policy #086 for infertility diagnosis and treatment
Surgical revisions/reconstruction
Revisions and reconstruction
Surgical revision guidance
Adolescents
Surgical services for adolescents
Adolescent-specific requirements and documentation
General coverage condition for listed codes
Coverage and medical necessity for listed CPT/HCPCS codes are subject to the policy's medical necessity criteria and the member's contract; certain procedures have been clarified or updated in policy history.
Providers must verify member contract benefits and meet documented criteria before coverage is approved.
General coverage condition
Covered when ALL of the following are met:
Policy references pages 2–7 for full medical necessity criteria; those criteria are required for coverage.
Code usage criteria
Codes listed in this section correspond to gender-affirming facial surgical procedures and should be billed when procedure, approach, and laterality match the operative documentation.
Ensure documentation supports action, approach, laterality, and tissue-substitute type when applicable.
Body contouring procedures that are unrelated to chest surgery and the procedures listed in this policy are considered investigational and not covered. Examples called out in the policy include buttocks enhancement, tracheal implant, breast lift, standalone lip enhancement, lip lift, monsplasty, dermabrasion, neck lift as a stand-alone procedure, chemical peel, electrolysis (except when authorized as part of genital surgery), and hair transplant.
Monsplasty is explicitly specified as a non-covered service in the policy history update effective 6/1/2024; this clarification appears in the non-covered services list alongside other investigational body contouring procedures and remains a stated exclusion.
Coverage for the CPT, HCPCS and ICD procedure codes listed in this document is conditional: the policy requires that the medical necessity criteria referenced on pages 2–7 be met and that an appropriate ICD-10 diagnosis (e.g., the F64.x series) be submitted. If those medical necessity criteria and diagnosis codes are not documented, the listed codes are not considered covered.
Operative reports must document the specific anatomic target, the surgical approach (open, percutaneous, percutaneous endoscopic, external), and laterality where applicable so that the chosen ICD-10-PCS code precisely matches the procedure description. The policy states codes should not be used unless the operative report documents the specific anatomic structure and approach matching the ICD-10-PCS descriptor.
This excerpt includes a listing of ICD-10-PCS procedure codes for gender-affirming facial and related surgeries; the listing itself does not contain additional explicit coverage determinations, medical necessity criteria or exclusions beyond those stated elsewhere in the policy.
The policy identifies several CPT codes as investigational for Commercial Blue members. Examples listed in the document include 15771, 15773, 15839, and 53899, which are noted as investigational and therefore excluded from coverage under the Commercial product referenced.
Reconstructive surgery following gender-affirming procedures may be considered medically necessary when performed to correct functional impairment or complications from the initial surgery. The policy explicitly states such reconstructive surgery is not medically necessary when performed to reverse natural signs of aging or solely because a member is dissatisfied with the surgical result.
Prior versions of the policy and historical updates addressed voice and speech therapy and related procedures. The policy history and prior statements document that specific positions on speech/voice services have been previously added or revised; earlier revisions included statements about voice/speech services and electrolysis limits that affected coverage determinations.
For Commercial members, the document indicates that the CPT/HCPCS/ICD procedure codes listed are considered covered only when the policy’s medical necessity criteria on pages 2–7 are met and the appropriate diagnosis codes (for example, F64.x) are submitted. Thus listed codes imply coverage when medical necessity criteria are documented for the member and product specified.
Use of procedure codes for gender-affirming facial surgery without supporting documentation of medical necessity and appropriate clinical indications may lead to claim denials. The policy warns that submitting these facial surgery codes absent documentation linking the procedure to the policy criteria may trigger denial or processing issues.
Diagnosis and Procedure Codes
| O8SQXZZ | Reposition Right Lower Eyelid; Percutaneous Approach (example entry) |
| O8SRXZZ | Reposition Left Lower Eyelid; Percutaneous Approach (example entry) |
| ONNCAZZ | Release Right Sphenoid Bone; Percutaneous Endoscopic Approach (example entry) |
| 17380 | Electrolysis epilation, each 30 minutes |
| 19325 | Breast augmentation with implant |
| 19350 | Nipple/areola reconstruction |
| 19357 | Tissue expander placement in breast reconstruction, including subsequent expansion(s) |
| 19380 | Revision of reconstructed breast |
| 53410 | Urethroplasty, 1-stage reconstruction of male anterior urethra |
| 53420 | Urethroplasty, 2-stage; first stage |
| 53425 | Urethroplasty, 2-stage; second stage |
| 54120 | Amputation of penis; partial |
| 54125 | Amputation of penis; complete |
| 21137 | Reduction forehead; contouring only |
| 21138 | Reduction forehead; contouring and application of prosthetic material or bone graft |
| 21139 | Reduction forehead; contouring and setback of anterior frontal sinus wall |
| 21175 | Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead |
| 21208 | Osteoplasty facial bones; augmentation (autograft, allograft, or prosthetic implant) |
| 21209 | Osteoplasty, facial bones; reduction |
| 21299 | Unlisted craniofacial and maxillofacial procedure |
| 21499 | Unlisted musculoskeletal procedure, head |
| 67900 | Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) |
| 21120 | Genioplasty; augmentation (autograft, allograft, prosthetic material) |
| 21121 | Genioplasty; sliding osteotomy, single piece |
| 21122 | Genioplasty; sliding osteotomies, 2 or more |
| 21123 | Genioplasty; sliding, augmentation with interpositional bone grafts |
| 21125 | Osteotomy; obtaining autograft (example) |
| 21127 | Osteoplasty; obtaining autograft (example) |
| 21208 | Osteoplasty facial bones; augmentation |
| 21209 | Osteoplasty facial bones; reduction |
| 21299 | Unlisted craniofacial and maxillofacial procedure |
| 21499 | Unlisted musculoskeletal procedure, head |
| 15876 | Suction assisted lipectomy; head and neck |
| 31599 | Unlisted procedure, larynx (vocal cord or tracheal procedures as indicated) |
| 15877 | Suction assisted lipectomy; trunk |
| 19303 | Mastectomy, simple, complete |
| 19316 | Mastopexy |
| 19318 | Breast reduction |
| 19350 | Nipple/areola reconstruction |
| 54660 | Insertion testicular prosthesis |
| 55175 | Scrotoplasty; simple |
| 55180 | Scrotoplasty; complex |
| 55980 | Intersex surgery; female to male |
| 56620 | Vulvectomy: simple |
| Q4116 | AlloDerm per sq cm |
| J3316 | Noted in policy as HCPCS/J-codes exempt from prior authorization (informational) |
| J9219 | Noted in policy as HCPCS/J-codes exempt from prior authorization (informational) |
| J9225 | Noted in policy as HCPCS/J-codes exempt from prior authorization (informational) |
| J9226 | Noted in policy as HCPCS/J-codes exempt from prior authorization (informational) |
| F64.0 | Transsexualism |
| F64.1 | Gender identity disorder in adolescence and adulthood |
| F64.2 | Gender identity disorder of childhood (as listed) |
| F64.8 | Other gender identity disorders |
| F64.9 | Gender identity disorder, unspecified |
| OVTCOZZ | Resection of Bilateral Testes, Open Approach (example) |
| OHOTOZZ | Alteration of Right Breast, Open Approach (example) |
| OHOT3ZZ | Alteration of Right Breast, Percutaneous Approach (example) |
| OHOUOZZ | Alteration of Left Breast, Open Approach (example) |
| OHOU3ZZ | Alteration of Left Breast, Percutaneous Approach (example) |
| OHOVO7Z | Alteration of Bilateral Breast with Autologous Tissue Substitute, Open Approach |
| OHOVOZZ | Alteration of Bilateral Breast, Open Approach |
| OHDSXZZ | Extraction of Hair, External Approach |
| O8ONOZZ | Alteration of Right Upper Eyelid, Open Approach |
| O8ONBZZ | Alteration of Right Upper Eyelid, Percutaneous Approach |
| O8ONXZZ | Alteration of Right Upper Eyelid, External Approach |
| O8OPOZZ | Alteration of Left Upper Eyelid, Open Approach |
| O8OP3ZZ | Alteration of Left Upper Eyelid, Percutaneous Approach |
| O8OPXZZ | Alteration of Left Upper Eyelid, External Approach |
| O8OQOZZ | Alteration of Right Lower Eyelid, Open Approach |
| O8OQ3ZZ | Alteration of Right Lower Eyelid, Percutaneous Approach |
| O8OQXZZ | Alteration of Right Lower Eyelid, External Approach |
| O8OROZZ | Alteration of Left Lower Eyelid, Open Approach |
| O8SNOZZ | Reposition Right Upper Eyelid, Open Approach |
| O8SNXZZ | Reposition Right Upper Eyelid, External Approach |
| O8SPOZZ | Reposition Left Upper Eyelid, Open Approach |
| O8SPXZZ | Reposition Left Upper Eyelid, External Approach |
| O8SQOZZ | Reposition Right Lower Eyelid, Open Approach |
| O8SQ3ZZ | Reposition Right Lower Eyelid, Percutaneous Approach |
| O8SROZZ | Reposition Left Lower Eyelid, Open Approach |
| O8SR3ZZ | Reposition Left Lower Eyelid, Percutaneous Approach |
| OKS1OZZ | Reposition Facial Muscle, Open Approach |
| OKS14ZZ | Reposition Facial Muscle, Percutaneous Endoscopic Approach |
| OVT9OZZ | Resection of Right Testis, Open Approach (example) |
| OVT94ZZ | Resection of Right Testis, Percutaneous Endoscopic Approach |
| OVTCAZZ | Resection of Bilateral Testes, Percutaneous Endoscopic Approach |
| OVTSOZZ | Resection of Penis, Open Approach |
| OVTS4ZZ | Resection of Penis, Percutaneous Endoscopic Approach |
| OVTSXZZ | Resection of Penis, External Approach |
Prior Authorization, Documentation, and Billing Guidance
Prior Authorization Required
Precertification is required for all inpatient services described in this policy. For outpatient services, prior authorization requirements vary by product: Commercial Managed Care (HMO and POS) and Commercial PPO/Indemnity generally require prior authorization for surgical services and fertility preservation (exceptions below); Medicare HMO requires prior authorization for surgical services, speech/voice training; Medicare PPO prior authorization not required for some outpatient services per product rules. Failure to obtain required precertification/prior authorization may result in claim denial.
- Inpatient: precertification/preauthorization IS REQUIRED for all products when procedure is performed inpatient.
- Commercial Managed Care (HMO and POS) Outpatient: prior authorization required for surgical services and fertility preservation; not required for surgically implanted puberty blockers.
- Commercial PPO and Indemnity Outpatient: prior authorization required for surgical services and fertility preservation; not required for surgically implanted puberty blockers.
- Medicare HMO BlueSm Outpatient: prior authorization required for surgical services, speech/voice training; not required for surgically implanted puberty blockers.
- Medicare PPO BlueSm Outpatient: prior authorization may not be required depending on product rules — verify member benefits.
Medical Necessity and Prior Authorization
All requests for services that are listed in the policy (including the ICD-10-PCS facial surgery codes and other procedure codes referenced) must meet the policy medical necessity criteria and, when required by product, have prior authorization submitted before the service.
- The medical necessity criteria (age, documented gender dysphoria F64.x, duration of gender identity, exclusion of alternative mental disorder, stable and documented gender identity) MUST be met for coverage of listed codes for Commercial members and Medicare products.
- Claims submitted without meeting these criteria or without appropriate prior authorization are at risk for denial.
Prior Authorization for ICD-10-PCS Facial Surgery Codes
Specific ICD-10-PCS facial surgery codes included in this policy require prior authorization when performed outpatient under products that mandate authorization. Ensure correct code selection (approach, laterality, and target structure) and submit operative documentation supporting the exact ICD-10-PCS code.
- Example ICD-10-PCS codes included: 0J043ZZ, OJ0S0ZZ, 0J053ZZ and many ONRC/ONRF/OW0 series codes for facial bone alteration and replacement — see policy code list.
- Documentation must specify approach (open, percutaneous, endoscopic, external), laterality (right/left/bilateral), and the target structure to justify the chosen ICD-10-PCS code.
- Prior authorization may be required per product; verify outpatient product rules before scheduling.
Prior Authorization Not Specified in This Section
The policy lists many ICD-10-PCS procedure codes only; this section does not by itself determine whether prior authorization is required for every listed code. Providers must check the member's specific product rules and the payer's outpatient authorization requirements.
- ICD-10-PCS lists are informational — verify prior authorization requirements with the member’s benefit plan.
- If product requires prior authorization for outpatient surgical services, include the listed ICD-10-PCS codes in the request.
Diagnosis and Criteria Required
Claims lacking the required F64.x diagnosis or failing to meet the stated policy criteria may be denied. When submitting authorization requests or claims, include the appropriate ICD-10 diagnosis code and documentation demonstrating how the medical necessity criteria are met.
- Required diagnosis codes: F64.0, F64.1, F64.2, F64.8, F64.9 when applicable.
- Explain how the member meets each element of the medical necessity criteria (age, duration of identity, stable documentation, exclusion of other mental disorder).
Potential Denial for Unsupported Codes
Unsupported or miscoded procedure claims and requests without adequate medical necessity documentation are at risk for denial. Use the correct procedure code set (CPT, HCPCS, ICD-10-PCS) and ensure the documentation supports the code(s) billed.
- Verify that the procedure code billed corresponds to the documented operative approach, laterality, and target structure.
- Codes not supported by documentation or listed as investigational in the policy may be denied for Commercial members.
Investigational CPT Codes — Denial Risk
Some CPT codes referenced in the policy are considered investigational or may be denied for Commercial Blue products. Review the policy’s CPT lists and the member’s contract; expect denials for codes explicitly marked investigational or not supported.
- Investigational CPT examples are noted in the policy code lists (e.g., certain body contouring/liposuction codes when not meeting criteria).
- If a CPT code is listed as investigational or not covered, request medical review prior to service or submit supporting documentation showing medical necessity and benefit coverage.
Submission Form and Contact
Providers must complete and fax the required Prior Authorization Request Form(s) when requesting authorization for gender affirming services. Contact numbers vary by line of business.
- Prior Authorization Request for Gender Affirming Services (Transgender Services) Form #901 must be completed and faxed.
- Form #902 is required for electrolysis where applicable.
- Fax numbers: Medical and Surgical: 1-888-282-0780; Medicare Advantage: 1-800-447-2994; BCBSMA Employees: 617-246-4299.
Required Documentation for Surgical Requests for Members <18
For surgical requests for members under 18, additional documentation is required even when services are considered on a case-by-case basis. Provide evidence of home support, mental health assessment, and informed expectations regarding long-term surgical consequences.
- Document adequate home support for the minor.
- Provide assessment of co-existing mental health concerns and confirmation that surgery is not an initial response to pubertal gender dysphoria.
- Document the minor’s realistic expectations and understanding of long-term surgical consequences.
Required Operative Documentation and Detail for Coding
Operative reports submitted for authorization or claims must include sufficient detail to support coding and medical necessity. Specify the surgical approach, laterality, and the exact target structure altered or replaced to ensure the claim maps to the correct ICD-10-PCS or CPT code.
- Include operative details: approach (open, percutaneous, endoscopic, external), laterality (right, left, bilateral), and target structure (e.g., sphenoid bone, ethmoid bone, jaw, breast tissue).
- For female-to-male chest and genital procedures, document the specific technique and structures addressed to support ICD-10-PCS procedure selection.
Formulary / Tiering Note for Hormone Therapy
Hormone therapy options may be subject to formulary or tiering restrictions and PBM rules. Prescribers and pharmacies should verify drug coverage, prior authorization (if applicable), and tiering through the member’s pharmacy benefit.
- Examples: estrogen, androgen-reducing medications (bicalutamide, spironolactone, GnRH agonists), progestins, and testosterone may be subject to formulary placement.
- Check pharmacy benefit and prior authorization requirements before initiating therapy.
Clinical Background and Scope
Gender dysphoria is the clinical condition addressed by this policy and generally refers to a marked incongruence between an individual’s assigned sex at birth and their experienced gender. The policy references diagnostic coding and standards of care (for example, DSM/WPATH guidance) and frames covered services—medical, behavioral, fertility preservation and surgical—within that clinical context.
Key Terms and Code Definitions
Policy History and Material Changes
Investigational indications were revised (policy history entry noting investigational indications revised).
Policy updated to clarify coverage for facial feminization procedures (e.g., orbital contouring) and to specify monsplasty as a non-covered service.
Investigational/non-covered services were added to the non-covered section and coding section clarified, including removal of hysterectomy and orchiectomy codes from prior authorization coding section.
Annual policy update incorporating WPATH v8 guidance and clarifications to hormone therapy and coding information.
Surgical procedures guidance revised to clarify staging of procedures and that hormone therapy is not required for transmasculine chest surgery; facial feminization statement clarified to include scalp advancement when needed.
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