Prior authorization required for gender-affirming services

Prior authorization is required for most gender-affirming surgical services, fertility preservation, and many outpatient surgical procedures per product. Complete and fax the appropriate Prior Authorization Request Form (Form #901 for Gender Affirming Services; Form #902 for Electrolysis) to the numbers on the forms prior to scheduling. Prior authorization is required for all inpatient procedures described in this policy for all products.

• Prior Authorization Request Form #901 — Gender Affirming Services (Transgender Services)
• Prior Authorization Request Form #902 — Electrolysis for Gender Affirming Services (Transgender Services)
• Fax: Medical and Surgical: 1-888-282-0780; Medicare Advantage: 1-800-447-2994; BCBSMA Employees: 617-246-4299

Male-to-Female Surgery — Prior Authorization

When requesting prior authorization for male-to-female genital procedures, include the corresponding ICD-10-PCS procedure codes listed in the policy and document how the member meets the medical necessity criteria. Coverage for these procedures is contingent on meeting the medical necessity criteria specified on pages 2-7 of the policy.

• Include ICD-10-PCS codes such as 0VTB0ZZ, 0VTB4ZZ, 0VTC4ZZ, 0VTS0ZZ, 0VTS4ZZ, 0VTSXZZ, 0W4M070, 0W4M0J0, 0W4M0K0 when applicable
• When submitting CPT/HCPCS codes, also include an appropriate ICD-10 diagnosis code from the F64.xx series

Facial Surgery — Prior Authorization

Prior authorization requests for facial gender-affirming procedures must reference the specific ICD-10-PCS codes listed in the facial surgery sections and include procedure-level documentation demonstrating how the member meets the medical necessity criteria. Include procedure codes for facial bone supplementation/alteration and soft tissue procedures as applicable.

• Examples of ICD-10-PCS codes: 080N0ZZ, 080P0ZZ, 090K0ZZ, 09QM0ZZ, 0J040ZZ, 08SN0ZZ, 0KS10ZZ, 0NQXXZZ, 0NRC07Z, 0NUC3JZ, 0NUF07Z (see policy for full lists)
• Include listed procedure codes for facial bone repair/replacement/supplementation and soft-tissue alterations when applicable

Coverage contingent on meeting medical necessity criteria

All requests for coverage of gender-affirming procedures must demonstrate that the member meets the policy's medical necessity criteria. Failure to meet those criteria will result in non‑coverage for Commercial members and applicable product lines. Claims submitted without required documentation or using procedure codes not listed may be subject to review or denial.

• The medical necessity criteria on pages 2–7 MUST be met for coverage
• Include supporting documentation such as two letters/assessments from licensed clinicians when required (see genital surgery requirements)
• Claims using ICD-10-PCS or CPT codes not present in the policy lists may trigger review or denial

Documentation for surgical candidates

Document surgical candidacy per the policy: for genital surgery (unless an exception such as MRKH applies) obtain and include two letters/assessments from licensed clinicians (e.g., behavioral health professional, primary care provider, or surgeon). For members <18, provide documentation of adequate home support, realistic expectations, and assessment of co‑existing mental health concerns. Include electrolysis documentation where required.

• Genital surgery: two letters/assessments from licensed and treating clinicians documenting criteria
• Adolescents (<18): documentation of home support, realistic expectations, and mental health assessment
• Electrolysis: refer to Form #902 and include number of treatments and medical necessity

Diagnosis linkage and documentation

When submitting authorization requests, include all relevant procedure and diagnosis codes and link each CPT/HCPCS code to an ICD-10 diagnosis from the F64.x series as appropriate. Providers should report services using current industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

• Include one of the F64.xx diagnosis codes (F64.0, F64.1, F64.2, F64.8, F64.9) with procedure codes
• Report services using up-to-date CPT/HCPCS/ICD-10 codes and modifiers

Prior authorization — include listed procedure codes

Include the specific procedure codes listed in the policy (ICD-10-PCS, CPT, and HCPCS) with authorization requests and claims. Procedure-level documentation demonstrating how the member meets medical necessity criteria must accompany the codes.

• Include listed ICD-10-PCS procedure codes for male-to-female, female-to-male, facial, and chest procedures as applicable
• HCPCS example: Q4116 (AlloDerm) — include with linked diagnosis code and supporting documentation

Authorization risk — none listed

No additional authorization risk categories are specified beyond the prior authorization and medical necessity requirements detailed above. Authorization review may occur when submitted codes or documentation do not align with the policy lists or criteria.

• Authorization risk: none explicitly listed in policy beyond review/denial when criteria or code lists are not met

Prior authorization forms and coding guidance

Complete the appropriate Prior Authorization Request Form and fax it with all supporting documentation (clinical records, letters of medical necessity, procedure codes, and diagnosis codes). For electrolysis requests, use Form #902 and indicate the number of treatments; >12 treatments require prior authorization with an additional letter of medical necessity.

• Form #901 — Gender Affirming Services (Transgender Services)
• Form #902 — Electrolysis for Gender Affirming Services (Transgender Services); >12 treatments require prior authorization