CurrentBlue Cross Blue Shield - MassachusettsPolicy 189

Gender‑Affirming Services Coverage Criteria

This policy governs coverage and medical necessity criteria for gender-affirming medical, behavioral health, fertility preservation, and surgical services for transgender and gender diverse members of Blue Cross Blue Shield - Massachusetts.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyGender‑Affirming Services Coverage Criteria

Policy CodePolicy 189

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization (use Form #901 or #902 as applicable) and document that the member meets Table 1 and any procedure‑specific criteria before scheduling surgical services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18baseline surgical age

12 monthsrequired duration of affirmed identity

24 monthsfertility storage max

Up to 12electrolysis for genital prep

Requiredprior authorization

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9CPT codes investigational

Coverage and Medical Necessity Criteria

Table 1 — General surgical criteria

Covered when ALL of the following are met

Table 1: Baseline surgical eligibility: Member is age ≥ 18; diagnosed with gender dysphoria (ICD-10 F64.0-F64.9); desire to live and be accepted as another gender, typically with desire for physical congruence via surgery and/or hormones; new gender identity present for at least 12 months; consistent, stable gender identity well documented by treating providers and, when possible, living as affirmed gender in safe settings; gender dysphoria is not a symptom of another mental disorder.

See Table 1 (chunk 11)

Table 2 — Procedure-specific criteria

Procedure-specific criteria (Table 2). Covered procedures when the additional criteria are met

Facial procedures: Facial feminization or masculinization procedures listed (orbital contouring/osteoplasty, scalp advancement as needed with forehead contouring, rhinoplasty, mandible reconstruction, trachea shave, blepharoplasty, brow lift, cheek augmentation); face lift or liposuction and neck lift covered only when needed in conjunction with the listed procedures. Procedures may be staged as needed.

See Table 2 (chunk 12)

Vocal cord surgery: Wendler glottoplasty for transfeminine members; treating surgeon must be board certified in Otolaryngology - Head and Neck Surgery; consultation with a voice and communication specialist is recommended to maximize outcomes.

See Table 2 (chunk 12)

Chest procedures: Mastectomy and/or creation of a male chest (with or without body contouring) for transmasculine/gender diverse members, and breast augmentation (with or without body contouring) for transfeminine members; hormone therapy is not required but for candidates without a medical contraindication a minimum of 12 months of continuous hormone therapy is recommended where applicable.12 months (when applicable)

See Table 2 (chunk 12)

Genital procedures: Genital gender affirming surgery for transmasculine, transfeminine, or gender diverse members (including penile construction using Alloderm); for candidates without medical contraindication, a minimum of 6 months of continuous hormonal therapy under supervision of a licensed clinician is recommended; genital surgery may require documentation by two licensed treating clinicians and procedures may be staged.6 months (when applicable)

See Table 2 (chunk 13)

Electrolysis for genital surgery: Electrolysis and/or laser hair removal performed by a licensed/certified provider for removal of hair on skin being used for genital gender affirmation surgery is covered up to 12 treatments; greater than 12 treatments requires prior authorization with a subsequent letter of medical necessity; electrolysis/laser for other body parts or indications is not covered.Up to 12 treatments

See Table 2 (chunk 13)

Surgical revisions/reconstruction

Reconstructive surgery covered when

Reconstructive indications: Reconstructive surgery following gender affirmation surgery (including facial surgery) is medically necessary when performed to correct complications resulting from the initial surgery OR to correct functional impairment resulting from the initial surgery.

Not medically necessary to reverse natural signs of aging or to address dissatisfaction with result (chunk 14)

Puberty blockers

Puberty suppression coverage

Puberty blockers criteria: Gonadotropin-releasing hormone (GnRH) analog treatment (puberty blockers) is covered at the discretion of the treating provider; WPATH Standards of Care (SOC8) recommended minimum criteria include: long-lasting/intense pattern of gender nonconformity or dysphoria; dysphoria emerged or worsened with onset of puberty; co-existing psychological/medical/social problems that could interfere with treatment have been addressed and functioning is stable enough to start treatment; adolescent has given informed consent and parents/guardians have consented when applicable.

See Puberty Blockers (chunk 6)

Hormone therapy

Hormone therapy coverage

Gender affirming hormone therapy is covered at the discretion of the treating provider and includes agents such as estrogen, androgen-reducing medications (e.g., bicalutamide, spironolactone, GnRH agonists, 5-alpha reductase inhibitors), progestins, and testosterone; methods of administration may be subject to formulary or tiering restrictions.

See Gender Affirming Hormone Therapy (chunk 7)

Behavioral health and voice therapy

Behavioral and voice services coverage

Behavioral health: Supportive behavioral health services (initial evaluation, counseling, psychotherapy) for transgender and gender diverse members are covered.

See Behavioral Health (chunk 8)

Speech/voice training: Feminizing or masculinizing speech therapy and/or voice training services are covered for transgender and gender diverse members (consultation with voice specialist recommended for surgical voice procedures per Table 2).

See Speech Therapy/Voice Training (chunk 16) and Table 2 (chunk 12)

Fertility preservation

Fertility preservation coverage

Cryopreservation: Oocyte, embryo, or sperm retrieval, freezing and storage for up to 24 months prior to genital surgery or hormone therapy may be considered medically necessary; adequate sperm/egg evaluation is required; cryopreservation is limited to one cycle per policy #086; members on hormone therapy must stop and assess gamete quality prior to cryopreservation.24 months

See Fertility Preservation (chunk 9)

Surgical services for adolescents

Adolescents <18

Adolescent surgical considerations: Members under 18 are considered on a case-by-case basis; in addition to meeting the Table 1 criteria, providers must document adequate home support, the member has realistic expectations and understanding of long-term consequences, and assessment that surgery is not being requested as an initial response to gender-dysphoric puberty.

See Surgical Services for Adolescents (chunk 15) and Table 1 (chunk 11)

General coverage condition for listed codes

Covered when ALL of the following are met:

Medical necessity and PA: The medical necessity criteria on pages 2-5 (Table 1 and Table 2) must be met for the listed CPT/HCPCS codes to be covered for Commercial Members (Managed Care HMO and POS, PPO, Indemnity) and Medicare HMO/PPO Blue; providers must verify member benefits and obtain required prior authorization where specified (prior authorization is required for most outpatient surgical services and fertility preservation; certain HCPCS codes are exempt).

See CPT/HCPCS guidance (chunk 34), outpatient prior auth rules (chunk 19), and ICD-10 diagnosis requirement (chunk 48)

Coverage contingent on medical necessity criteria (codes section)

Covered when ALL of the following are met:

Coverage contingent on medical necessity criteria: The CPT/HCPCS/ICD-10/ICD-10-PCS codes listed in this policy are considered medically necessary for Commercial Members only when the medical necessity criteria on pages 2-7 of the policy are satisfied; inclusion of a code alone does not guarantee coverage and providers must confirm member contract benefits and prior authorization requirements.

See ICD-10 diagnosis list and code coverage statement (chunk 48) and code inclusion note (chunk 34)

The policy identifies a set of procedures that are considered investigational and not covered. Examples include body contouring unrelated to chest surgery, rib remodeling, buttocks enhancement, tracheal implant, breast lift, buccal fat pad removal, hair transplant, and electrolysis (except when performed for genital surgery preparation). This list is illustrative rather than exhaustive; procedures described as investigational in the policy will be denied when billed under those indications.

Inclusion of a CPT, HCPCS, or ICD code in this policy document is for informational purposes only and does not by itself guarantee member coverage or provider reimbursement. Providers and billing staff must verify coverage by reviewing the member’s specific contract benefits in effect at the time of service.

Coverage for the codes listed in this policy is conditioned on product type and the policy’s medical necessity requirements. The listed codes are considered for coverage only for Commercial Members (Managed Care HMO and POS, PPO, Indemnity) and Medicare HMO Blue / Medicare PPO Blue and only when the policy’s medical necessity criteria on pages referenced are met. Providers must verify member benefits and obtain any required prior authorization.

A subset of CPT codes has been explicitly identified in the policy as investigational for Commercial Members. The policy lists codes including 15771, 15773, 15774, 15839, and 53899 as investigational for the conditions noted; use of these codes for the specified procedures is excluded from coverage as investigational and may trigger denial.

Reconstructive surgery following gender-affirming procedures is considered medically necessary when it is performed to correct complications of the initial surgery or to correct functional impairment resulting from the initial surgery. Reconstructive surgery is not medically necessary when performed solely to reverse natural signs of aging or because the member is dissatisfied with the surgical result.

The policy history documents prior revisions in which certain procedures were newly designated investigational or not medically necessary. Examples include additions and clarifications to the investigational/non-covered list and historic changes to statements on breast lift and electrolysis; these prior actions inform the current non-covered and investigational lists in the policy.

Coverage for the procedures and codes listed in this section is contingent on meeting the policy’s medical necessity criteria (referenced on pages 2–7). If those medical necessity criteria are not satisfied, the listed procedures and associated codes are not covered for the member.

Procedure and Diagnosis Codes

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Precertification/preauthorization is required for all inpatient procedures described in this policy. For outpatient surgical services, prior authorization requirements vary by product — commercial managed care (HMO/POS), PPO/Indemnity, and Medicare HMO Blue generally require prior authorization for surgical services and fertility preservation; prior authorization is not required for surgically implanted puberty blockers for most products. Use the Prior Authorization Request for Gender Affirming Services (Form #901) or the Electrolysis form (#902) and fax to the numbers provided when seeking authorization.

Inpatient procedures: precertification/preauthorization IS REQUIRED for all products.
Outpatient procedures: prior authorization required for surgical services and fertility preservation for Commercial Managed Care (HMO/POS) and PPO/Indemnity; Medicare HMO Blue requires prior authorization for surgical services and select voice/speech services.
Prior Authorization forms: Form #901 (Gender Affirming Services) and Form #902 (Electrolysis). Fax numbers: Medical and Surgical: 1-888-282-0780; Medicare Advantage: 1-800-447-2994; BCBSMA Employees: 617-246-4299.

Clinical Background and Scope

Gender dysphoria describes a marked incongruence between assigned sex at birth and the individual’s experienced gender identity. Treatment options addressed in this policy include puberty suppression, gender-affirming hormone therapy, behavioral health and voice services, fertility preservation, and surgical interventions. The policy references accepted standards (for example WPATH) as part of recommended minimum criteria for some services.

Key Terms and Coding Definitions

Gender dysphoria / gender identity disorder — definitions & codes

DSM-5 definition referencedPer DSM-5, gender dysphoria is when a person's gender at birth is contrary to the one they identify with (policy notes DSM-5 definition)

ICD-10 diagnosis seriesICD-10-CM codes F64.0–F64.9 (Transsexualism and related gender identity disorder codes) are used for claims and are the diagnoses considered when medical necessity criteria are met

Policy context for termPolicy addresses gender-affirming services for transgender and gender diverse individuals when gender identity differs from assigned sex at birth

Medical necessity criteria — coverage condition

Medical necessity requirement for coverageThe medical necessity criteria on pages 2-5 (policy Tables 1 and 2) MUST be met for the listed CPT/HCPCS/ICD-10 codes to be covered for Commercial Members

Inclusion of codes not guarantee coverage

Policy Revision Timeline

2026-05-01policy_revisionLatest

Clarifications made to the noncovered section; effective 5/1/2026.

2025-11-01policy_update

Annual policy update; description, summary, and references reviewed; coding information clarified (no changes to clinical policy statements).

2025-01policy_revision

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyGender‑Affirming Services Coverage Criteria

Policy CodePolicy 189

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization (use Form #901 or #902 as applicable) and document that the member meets Table 1 and any procedure‑specific criteria before scheduling surgical services.

SourceLink

On This Page

Billing Rule

Use Listed ICD-10-PCS Codes for Authorization Requests

When submitting authorization requests for inpatient procedures or when prior authorization is required for outpatient procedures, include the exact ICD-10-PCS procedure codes from the policy (e.g., the listed ranges for gender-affirming facial surgery and female-to-male procedures). Use the ICD-10-PCS codes provided in the policy when seeking authorization if required.

Use the listed ICD-10-PCS codes for gender-affirming facial surgery and FTM procedures (see policy code lists).
Precise procedure coding reduces claim processing issues and supports the authorization review.

Denial Risk

Investigational CPT Codes — Potential Denial

Certain CPT codes are designated investigational for Commercial Members; prior authorization may be required but coverage is not provided for investigational procedures and authorization requests for these CPT codes are likely to be denied.

Investigational CPT codes include (but are not limited to): 15771, 15773, 15774, 15839, 53899.
Requests using these CPT codes for the listed indications are considered investigational and are subject to denial even if prior authorization is requested.

Note

Medical Necessity Required for Coverage; No Separate Authorization Acceptance Criteria in Code Lists

Coverage for the listed surgical procedure codes is contingent upon meeting the medical necessity criteria (Table 1 and Table 2). The policy excerpt with the code lists does not itself provide additional authorization acceptance or explicit denial criteria beyond requiring that medical necessity criteria be met.

The code lists are informational; inclusion does not guarantee coverage — the medical necessity criteria must be documented and met.
The policy code lists do not specify separate authorization acceptance thresholds or explicit denial criteria beyond the medical necessity requirements.

Documentation Required

Adolescent-Specific Documentation Required

For members under 18, providers must submit additional documentation when requesting surgery. This must demonstrate adequate home support, realistic expectations about surgical outcomes and long-term consequences, and assessment of co-existing mental health concerns; surgery for adolescents is considered on a case-by-case basis.

Required adolescent-specific documentation: adequate home support; realistic expectations and understanding of long-term consequences; assessment and documentation of co-existing mental health concerns showing surgery is not an initial response to gender-dysphoric puberty.
Members <18 are evaluated individually and additional evidence is required to justify medical necessity for surgery.

Billing Rule

Diagnosis and Criteria Required on Claims

When submitting claims or authorization requests, include an ICD-10 diagnosis from the F64.x series (e.g., F64.0–F64.9) to correspond with the CPT/HCPCS/ICD-10-PCS procedure codes and demonstrate that the medical necessity criteria have been met.

Required diagnosis codes: F64.0, F64.1, F64.2, F64.8, F64.9 when appropriate and supported by documentation.
Documentation must support that the member meets Table 1 and Table 2 medical necessity criteria when submitting the procedure codes.

Documentation Required

Code Lists Do Not Replace Required Clinical Documentation

The policy excerpts that list codes do not include full documentation templates or an exhaustive list of required supporting records; providers must still supply all clinical documentation demonstrating that the member meets the medical necessity criteria (e.g., provider notes, behavioral health letters, hormone therapy history where applicable).

Code lists alone are not sufficient — include clinical records, letters of support, hormone therapy documentation, and any other evidence required by Table 1/Table 2 or product-specific authorization rules.
If documentation demonstrating medical necessity is not provided, authorization or claims may be denied.

Step Therapy

Step Therapy / Medication Sequencing

Step therapy and medication sequencing are not specified in this policy excerpt. Puberty blockers and gender-affirming hormone therapies are covered at the discretion of the treating provider and may be subject to formulary or tiering restrictions as applicable to the member's benefit plan.

No step therapy requirements are listed in this excerpt for puberty blockers or hormone therapies.
Coverage of medications remains subject to the member's pharmacy benefits, formulary placement, and any prior authorization requirements for the specific drug codes (note: certain HCPCS injection codes are exempt from prior authorization as noted in the policy).

Inclusion or exclusion of a code in the policy does not by itself constitute member coverage or provider reimbursement; verify member contract benefits

Scope of applicable productsCriteria apply to Commercial Members (Managed Care HMO/POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue as specified

Gender dysphoria / gender identity disorder codes

ICD-10 codes for gender dysphoriaICD-10-CM codes F64.0–F64.9 (F64.0 Transsexualism; F64.1 Gender identity disorder in adolescence and adulthood; F64.2 Gender identity disorder of childhood; F64.8 Other identity disorders; F64.9 Gender identity disorder, unspecified)

Use with CPT/HCPCS for claimsAn ICD-10 diagnosis from the F64.x series must be submitted with CPT/HCPCS codes for coverage determinations

Diagnosis terminology noteAlthough DSM-5 uses 'gender dysphoria,' ICD-10 codes continue to use the term 'gender identity disorder' for claims submission

Supplement (ICD-10-PCS) — definition & context

Definition — supplement (ICD-10-PCS)Procedures that add tissue substitutes (autologous, synthetic, nonautologous) to anatomical sites such as breast, nipple, vagina, clitoris, penis via various approaches are classified as 'Supplement' in ICD-10-PCS

Examples of supplement codesExamples include codes for supplementing breast or vaginal sites with autologous, synthetic, or nonautologous tissue substitutes (see ICD-10-PCS code lists)

Applicable surgical contextsUsed throughout the policy for gender-affirming facial and genital procedures involving tissue substitutes

Creation of Penis (ICD-10-PCS) — examples

Creation of penis — ICD-10-PCS examplesProcedures creating a penis in the female perineum using autologous, synthetic, or nonautologous tissue substitutes are listed (example codes: 0W4N071, 0W4N0J1, 0W4N0K1)

Approach types includedCodes encompass open, percutaneous endoscopic, and external approaches for penile creation in the female perineum

Coverage linkageThese ICD-10-PCS procedure codes are included in the policy's female-to-male surgery section and are subject to the policy's medical necessity criteria

Investigational indications revised.

2024-06-01policy_revision

Policy updated to clarify coverage for facial feminization procedures (e.g., orbital contouring) and clarified non-covered services to specify monsplasty.

2023-12policy_revision

Investigational/non-covered services added to the non-covered section; coding section clarified and removal of hysterectomy and orchiectomy codes from prior authorization coding section.

2023-02policy_update

Annual policy update; WPATH version 8 guidelines and references reviewed and added; clarifications to hormone therapy and coding information.

2021-12policy_revision

Policy statements clarified to note surgical procedures may be staged, include scalp advancement as needed with forehead contouring, and hormone therapy not required for transmasculine chest procedures.

2021-10-01policy_revision

Policy revised to include medically necessary statements for vocal cord surgery for transfeminine members; effective 10/1/2021.

2021-06policy_revision

Clarified that neck lift is covered only if excess skin impairs outcome of covered facial procedures; prior authorization table updated to state surgically implanted puberty blockers do not require prior authorization.

2021-05policy_revision

Fertility preservation policy statement clarified to meet policy intent.

2020-12-09policy_revision

Penile construction following transgender surgery using Alloderm designated as covered; coding information clarified; effective 12/9/2020.

2020-05-01policy_revision

Electrolysis/laser hair removal treatments revised: up to 12 treatments covered following approval of genital surgery; >12 requires prior authorization with letter of medical necessity.

2019-09-01policy_revision

Policy revised to add not medically necessary statements on breast lift, include speech/voice training services as medically necessary, indicate prior authorization required for Medicare HMO, and update terminology and therapy options.

2019-03-01policy_revision

Policy updated with clarifications to surgical revisions; effective 3/1/2019.

2019-02-01policy_revision

Revisions to include new medically necessary statements on hormone therapy/puberty blockers, surgical services for adolescents, supportive behavioral health services; vocal cord surgery listed investigational at that time.

2018-10policy_revision

Clarified coding information.

2017-12policy_revision

Medically necessary criteria revised and new investigational indications described; coding clarified.