CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy | Gender Reassignment Surgery

Policy documents coverage and clinical criteria for gender reassignment surgery (GRS) for Medicare Advantage Plans and Commercial products, lists medically necessary procedures for transwomen and transmen, documentation requirements, prior authorization expectations, and CPT coding/billing instructions.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Gender Reassignment Surgery

Policy CodePolicy N/A

Change TypeNo material change reported

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionSubmit required behavioral health, treating physician, and surgeon letters and obtain prior authorization for Medicare Advantage (recommended for Commercial).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this update.

MultipleCovered procedures

12 monthsReal-life experience

RequiredPreauthorization MA

6 monthsDSM‑5 symptom duration

Coverage Summary

This policy covers Gender Reassignment Surgery (GRS) for Medicare Advantage Plans and Commercial products and sets the conditions under which specific procedures are considered medically necessary. Coverage stance is mixed: GRS procedures are covered when the plan includes the benefit and the individual meets the policy's documented medical necessity criteria; some procedures (e.g., hair removal for donor sites) are covered only in specified clinical circumstances while others are considered cosmetic and noncovered. Prior authorization is required for Medicare Advantage and recommended for Commercial plans to determine eligibility and benefit applicability.

Medical Necessity / Eligibility Criteria

General Eligibility / Medical Necessity

When a benefit for gender reassignment surgery exists, it is considered medically necessary when documentation confirms that all of the following criteria are met:

Diagnosis: The individual has been diagnosed with the gender identity disorder (GID) or gender dysphoria of transsexualism
Real-life experience: The individual has successfully lived and worked within the desired gender role full-time for at least 12 months (real-life experience) without returning to the original genderFull-time living and working in desired gender role for at least 12 months
Real-life experience requirement; letters should document extent of participation and others' awareness during the 12-month period

Documentation / Comprehensive Evaluation

Comprehensive evaluation is generally supported by the following documentation (letters and documentation requirements):

Behavioral health letter: One letter from a behavioral health professional with a doctoral degree capable of evaluating co-morbid psychiatric conditions
Treating physician or behavioral health provider letter
- Team membership: Whether the author is part of a gender identity disorder treatment team
- Identifying characteristics: The candidate's general identifying characteristics
- Diagnoses: The initial and evolving gender, sexual, and other psychiatric diagnoses
- Duration and therapy type:

Surgeon Letter Requirements

All letters from a treating surgeon must confirm the following:

Eligibility confirmation: The candidate meets the eligibility criteria listed in this policy
Benefit expected: The treating surgeon feels that the candidate is likely to benefit from surgery
Communication with treating providers: The surgeon has personally communicated with the treating mental health provider or physician treating the candidate
Patient understanding: The surgeon has personally communicated with the candidate and that the candidate understands the ramifications of surgery

DSM-5 / Diagnostic Criteria Context

DSM V criteria and related exclusionary points referenced as background for diagnosis:

Duration and indicators: Discomfort with assigned sex or gender role for at least six months, as manifested by at least two specified indicators (a–f listed in policy)At least six months with two or more indicators
Exclusionary conditions: The individual does not have an intersex or developmental condition
Distress or impairment: The condition causes clinically significant distress or impairment in social, occupational, or other areas of functioning
NOS note:

Coding and Billing

Covered CPT codes for gender reassignment procedures (Medicare Advantage & Commercial when criteria met)CPTCovered

19301	Mastectomy, partial
19303	Mastectomy, simple, complete
19316	Mastopexy
19318	Breast Reduction
19324	Mammaplasty, augmentation; without prosthetic implant
19325	Breast augmentation with implant
19350	Nipple/areola reconstruction
31899	Unlisted procedure, trachea, bronchi (trachea shave/reduction thyroid chondroplasty noted)
53430	Urethroplasty, reconstruction of female urethra
54125	Amputation of penis; complete

1–10 of 50

1/5

Unlisted CPT for hair removal claims (required for claims processing)CPT

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue (used for laser hair removal claims meeting coverage criteria)

CPT codes NOT to be used for pricing/processingCPT

55970	Intersex surgery; male to female (do not use for pricing/processing)
55980	Intersex surgery; female to male (do not use for pricing/processing)

Provider Actions & Billing Rules

Prior Authorization

Preauthorization required for Medicare Advantage

Prior authorization is required for Medicare Advantage Plans to determine eligibility and benefit applicability; recommended for Commercial groups.

Documentation Required

Submit required evaluation letters and surgeon documentation

Providers must submit behavioral health and treating physician letters documenting the items listed in the policy (diagnosis, duration, treatments, real-life experience, rationale, compliance) and a surgeon letter confirming eligibility, benefit, communication with treating providers, and patient understanding.

Behavioral health letter from a doctoral-level clinician documenting psychological aspects of GID
Treating physician or behavioral health provider letter (minimum 12 months of treatment or combined documentation) documenting: whether author is part of a GID treatment team; candidate demographics; initial and evolving diagnoses; duration and type of professional relationship; which eligibility criteria have been met; rationale for surgery; degree of compliance and likelihood of future compliance; extent of psychotherapy during 12-month real-life trial; that others were aware of the candidate’s real-life experience; status of legal name change
Surgeon letter confirming: candidate meets policy eligibility criteria; surgeon believes candidate will benefit; surgeon has communicated with treating mental health provider/physician; surgeon has communicated with the candidate and that the candidate understands surgical ramifications

Billing Rule

Claims for laser hair removal

Claims meeting coverage criteria for laser hair removal (for donor sites) must be submitted with unlisted CPT code 17999. CPT codes 55970 and 55980 are not to be used for pricing or claims processing; instead file claims with the specific procedures.

Affected codes: 17999, 55970, 55980
Use CPT 17999 for hair removal donor site claims
Do not use 55970 or 55980 for pricing/processing; file claims with the specific procedures

Background & Guidance References

The policy defines GRS as a multi-modality treatment for gender dysphoria that includes medical, psychiatric, and surgical interventions performed in conjunction to achieve successful behavioral and medical outcomes. It references DSM criteria (DSM‑V) for gender dysphoria and cites WPATH Standards of Care and the Endocrine Society guidelines as part of the supporting framework.

Emphasis is placed on comprehensive evaluation and documentation prior to irreversible surgery: patients typically undergo hormone therapy (commonly for 12 continuous months prior to surgery), must demonstrate a period of real-life experience (living and working full-time in the desired gender role for at least 12 months), and require corroborating behavioral health and treating physician documentation. The policy further requires that the treating surgeon confirm eligibility, discuss benefits and risks with the patient, and communicate with treating mental health or medical providers, and it recommends the surgeon have demonstrated competency with long-term follow-up.

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