Gender Reassignment Surgery Precertification Request Form — Coverage Criteria
Customize your policy alerts
Sign up for all blue cross blue shield - minnesota policy alerts
Know when blue cross blue shield - minnesota releases new policies or updates existing guidance.
Monitor payer policy activity
This form governs prior authorization/precertification submission requirements for gender-affirming surgical procedures and documents the clinical documentation required to evaluate requests; it affects providers submitting authorization for gender-affirming surgeries.
No material clinical or coverage changes in this revision.
Coverage Criteria for Gender-Affirming Procedures
Mastectomy (FTM)
Mastectomy (female-to-male) is covered when ALL of the following are met
See ADDITIONAL INFORMATION for letter content
Hysterectomy/ovariectomy (FTM)
Hysterectomy/ovariectomy is covered when ALL of the following are met
If contraindicated or unable, attach clinical documentation
See ADDITIONAL INFORMATION for letter content
Metoidioplasty/Phalloplasty (FTM)
Metoidioplasty or phalloplasty is covered when ALL of the following are met
If contraindicated or unable, attach clinical documentation
See ADDITIONAL INFORMATION for letter content
Breast augmentation (MTF)
Breast augmentation (MTF) is covered when ALL of the following are met
If contraindicated or unable, attach clinical documentation
Orchiectomy/Penectomy (MTF)
Orchiectomy/penectomy is covered when ALL of the following are met
If contraindicated or unable, attach clinical documentation
Vaginoplasty (MTF)
Vaginoplasty is covered when ALL of the following are met
If contraindicated or unable, attach clinical documentation
See ADDITIONAL INFORMATION for letter content
Non-binary affirmation procedures
Female or Male to Gender Neutral (Non-binary) affirmation surgeries are covered if ANY ONE of the procedure-specific sets below are met
See ADDITIONAL INFORMATION for letter content
This precertification form references the insurer's full medical policy for Gender Reassignment Surgery for detailed coverage limits, definitions, and exclusions. Providers must use the Gender Reassignment Surgery Precertification Request Form when requesting prior authorization and include required CPT and ICD-10 codes, tentative surgery date, and supporting clinical documentation as specified by the medical policy and the form.["0"]
Procedures will not meet criteria if the submission lacks documentation demonstrating persistent and well-documented gender dysphoria as defined on the form using DSM-5 elements, including evidence of clinically significant distress/impairment and at least 6 months duration with two or more listed manifestations. Additionally, required mental health evaluations/letters (one or two letters depending on procedure) that meet the form’s referral-letter requirements are necessary; absence of these letters or of required therapy durations may result in a determination that the request is not medically necessary.["4","5"]
Required Codes and Related Attributes
| CPT code | Procedure(s) requested — applicant must list specific CPT code(s) on form |
| ICD-10 | Diagnosis code(s) — applicant must list specific ICD-10 code(s) on form |
Precertification & Submission Requirements (What Providers Must Do)
Precertification required
Precertification is required. Use the Gender Reassignment Surgery Precertification Request Form and include the requested CPT and ICD-10 codes, tentative surgery date, and supporting clinical documentation. Incomplete submissions — for example missing required referral letters, hormone therapy documentation, CPT/ICD codes, tentative date of surgery, facility or surgeon information, or signatures — may delay the review or result in denial. Ensure the form is complete before submission.
- Use the Gender Reassignment Surgery Precertification Request Form
- Include CPT and ICD-10 diagnosis codes and a tentative date of surgery
- Missing documents or incomplete fields may delay or cause denial
Hormone therapy documentation
Documentation of 6 months of continuous hormone therapy is required for many procedures unless the patient has a documented medical contraindication or is unable/unwilling to take hormones. If a contraindication or inability to take hormones exists, attach supporting clinical documentation explaining the reason.
- 6 months continuous hormone therapy required unless contraindicated or unable/unwilling to take hormones
- If hormonally contraindicated or unable, attach clinical documentation
Required submission documents
Submit the completed Precertification Request Form with the following supporting documents and information: patient demographics and member ID; facility name, address, NPI or provider ID, phone and fax; surgeon and mental health provider names, credentials, addresses and contact info; CPT and ICD-10 codes for the requested procedure(s); tentative date and type of admission; and the requesting provider's signature and date. Failure to include these items may result in delayed processing or denial.
- Patient name, DOB, member ID, phone
- Facility and surgeon information, including NPI/provider ID
- CPT and ICD-10 codes, tentative surgery date, type of admission
- Requesting provider signature and date
Procedure-specific documentation
Procedure-specific documentation must be attached per the requested surgery: mental health referral letters (minimum of a master’s degree clinician) — one or two letters depending on procedure — and any procedure-specific items such as evidence of 12 months real-life experience where required, or confirmation of informed consent and discussion of reproductive effects. Referral letters should follow WPATH criteria (see ADDITIONAL INFORMATION) and include the clinician relationship, psychosocial assessment, statement that criteria for surgery are met, and availability for coordination of care.
- One referral letter required for procedures such as mastectomy or breast augmentation (see form)
- Two referral letters required for procedures such as hysterectomy, metoidioplasty, phalloplasty, vaginoplasty, penectomy/orchiectomy (see form)
- If first letter is from the treating psychotherapist, the second must be from a clinician who performed an evaluative role only
- Attach documentation of 12 months living in affirmed gender role when required
Incomplete submission risk
An incomplete submission — missing required referral letters, missing hormone therapy documentation or contraindication notes, absent CPT/ICD codes, missing tentative surgery date, or unsigned forms — increases the risk of delayed review or denial. Confirm all required items are present and that mental health letters meet the WPATH-specified content before submitting.
- Missing referral letters or letters that do not meet WPATH content criteria
- Absent or incomplete hormone therapy documentation or contraindication explanation
- Missing CPT/ICD codes, tentative date, facility/surgeon info, or provider signature
Key Definitions and Referral Letter Expectations
Background and Context
The form requires evaluation of persistent gender dysphoria using DSM-5 criteria, documenting clinically significant distress or impairment and a marked incongruence between experienced/expressed gender and assigned gender present for at least 6 months. The DSM-5-based checklist on the form lists manifestations (for example, incongruence with primary/secondary sex characteristics, strong desire to be rid of those characteristics, desire to be of the other gender, or to be treated as another gender). For referral-letter content and clinical rationale, the form references the WPATH Standards of Care, Version 8, for the specific elements mental health letters should address (identifying information, psychosocial assessment and diagnoses, duration and nature of the therapeutic relationship, prior options attempted, clinical rationale that criteria are met, statement of informed consent, and availability for coordination of care).["5","17"]
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.