CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Gender Affirming Care Coverage Criteria

Coverage guidelines for gender-affirming care services for Medicare Advantage Plans and Commercial Products offered by Blue Cross Blue Shield - Rhode Island, including eligibility, required prior authorization, and lists of covered procedures and applicable coding.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyGender Affirming Care Coverage Criteria

Policy CodePolicy N/A

Change TypeMinor / no material changes

Effective Date01|01|2024

Next Review DateN/A

Key ActionObtain prior authorization for Medicare Advantage members and verify benefits and eligibility before filing services for gender-affirming care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsrequired duration living full-time in congruent gender role for eligibility

6ICD-10-CM diagnosis codes listed for primary diagnosis

ManyProcedure CPT codes enumerated for potential coverage

SomeSome services exempt from additional medical necessity review

2Codes not to be used for pricing/processing

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Coverage Criteria

General coverage criteria

Covered when ALL of the following are met

Eligibility: Member has a diagnosis of gender dysphoria; member has successfully lived and worked in a gender role congruent with their gender identity full-time for at least 12 months; Gender Affirming Care is a covered benefit under the member's plan

These are required to consider listed procedures for coverage

Filing requirements: Procedure is performed for the purpose of gender affirming care and filed with one of the listed ICD-10-CM gender dysphoria diagnosis codes as the primary diagnosis

Some services marked with * may be covered without additional medical necessity review when eligibility and filing criteria are met

Inclusion of a service in this policy does not by itself guarantee coverage. Benefit determination for any requested surgery or gender-affirming care service depends on the member-specific Benefit Booklet, Evidence of Coverage or Subscriber Agreement and any group-specific benefits or exclusions. For member-specific coverage decisions, refer to the member contract language or call the provider call center.

The CPT codes 55970 and 55980 are not to be used for pricing or claims processing in lieu of specific procedure codes. Claims for services addressed in this policy should be filed with the applicable specific procedure CPT codes listed elsewhere in the document; when no specific code exists follow the Unlisted Procedures Payment Policy claim filing instructions.

If a service is determined to be not medically necessary (or is a non-covered benefit under the member's plan), the provider may not bill the member unless the member has been informed in advance and has agreed in writing to continue with the treatment at their own expense. Providers should refer to their participation agreement for applicable provisions and verify member benefits and eligibility before proceeding.

Coding

ICD-10-CM Diagnosis Codes (must be primary)ICD-10

F64.0	Gender identity disorder of childhood (listed)
F64.1	Dual-role transvestism (listed)
F64.2	Gender identity disorder of adolescence and adulthood, nontranssexual type (listed)
F64.8	Other gender identity disorders (listed)
F64.9	Gender identity disorder, unspecified (listed)
Z87.890	Personal history of sex reassignment (listed)

CPT Procedure Codes (enumerated in policy)CPT

19301	Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)
19303	Mastectomy, simple, complete
19316	Mastopexy
19318	Breast Reduction
19325	Breast augmentation with implant
19350	Nipple/areola reconstruction
31899	Unlisted procedure, trachea, bronchi (used for trachea shave/reduction thyroid chondroplasty)
53430	Urethroplasty, reconstruction of female urethra
54125	Amputation of penis; complete
54520	Orchiectomy, simple (including subcapsular), with or without testicular prosthesis

1–10 of 135

1/14

Covered CPT CodesCPT

11921	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin; 6.1 to 20.0 sq cm.
11922	Tattooing; each additional 20.0 sq cm, or part thereof.
11950	Subcutaneous injection of filling material (eg, collagen); 1 cc or less.
11951	Subcutaneous injection of filling material; 1.1 to 5.0 cc.
11952	Subcutaneous injection of filling material; 5.1 to 10.0 cc.
11954	Subcutaneous injection of filling material; over 10.0 cc.
14000	Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less.
14001	Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm.
14041	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm.
15734	Muscle, myocutaneous, or fasciocutaneous flap; trunk.

1–10 of 85

1/9

Hair Removal CodesCPT

17380	Electrolysis epilation, each 30 minutes.
17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue (used for laser hair removal per guidance).

Codes not to be used for pricing/processingCPTNot Covered

55970	Intersex surgery; male to female (not to be used for pricing/claims processing here).
55980	Intersex surgery; female to male (not to be used for pricing/claims processing here).

Real-life full-time living requirement — >= 12 months

Required durationMember must have lived and worked full-time in a gender role congruent with their gender identity for at least 12 months

Diagnosis requirementDocumentation must confirm a diagnosis of gender dysphoria (filed as the primary ICD-10-CM diagnosis)

PurposeFull-time living/work duration is required to determine eligibility for gender-affirming care under this policy

Fat graft injectate thresholds — per-code volume thresholds

15771Grafting of autologous fat to trunk/breasts/scalp/arms/legs; 50 cc or less injectate

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products to determine member eligibility for all services in this policy. See Eligibility Criteria in the Policy Statement. Verify member-specific prior authorization requirements per the member's plan document and the Prior Authorization of Services, Treatments or Procedures policy in Related Policies.

Prior authorization required for Medicare Advantage Plans.
Prior authorization recommended for Commercial Products.
Confirm prior authorization requirements with member-specific benefits and the Prior Authorization policy.

Documentation Required

Exceptions to Prior Authorization for Medical Necessity Review

Certain services marked with an asterisk in the Policy Statement may be covered without additional medical necessity review when all of the following are met: eligibility criteria are satisfied, the service is performed for gender affirming care, the claim is filed with an ICD-10-CM diagnosis code for gender dysphoria, and Gender Affirming Care is a covered benefit under the member's plan. Examples include Facial Surgery*, Hair Removal/Transplant*, Lipoplasty*, Vocal Cord Surgery*.

Definitions

Eligibility for Gender Affirming Care — diagnosis and full-time congruent living/work requirement

Primary diagnosisMember must have a diagnosis of gender dysphoria filed as the primary ICD-10-CM code to support coverage consideration

Full-time congruent living/workMember must have lived and worked in a gender role congruent with their gender identity full-time for at least 12 months

Plan benefitGender affirming care must be a covered benefit under the member's specific plan for services to be considered

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyGender Affirming Care Coverage Criteria

Policy CodePolicy N/A

Change TypeMinor / no material changes

Effective Date01|01|2024

Next Review DateN/A

Key ActionObtain prior authorization for Medicare Advantage members and verify benefits and eligibility before filing services for gender-affirming care.

SourceLink

On This Page

Each additional 50 cc injectate (list separately in addition to code for primary procedure)

15773Grafting of autologous fat to face/eyelids/mouth/neck/ears/orbits/genitalia/hands/feet; 25 cc or less injectate

15774Each additional 25 cc injectate (list separately in addition to code for primary procedure)

Covered without additional medical necessity review when: eligibility criteria met; performed for gender affirming care; filed with a gender dysphoria ICD-10-CM code; benefit for Gender Affirming Care exists on the member's plan.
Examples: Facial Surgery*, Hair Removal/Transplant*, Lipoplasty*, Vocal Cord Surgery*.

Billing Rule

Unlisted Code Submission & Benefit Verification

When a service does not have a specific CPT code and is billed with an unlisted CPT, follow the Unlisted Procedures Payment Policy for claim submission. Always verify member benefits for applicable surgery/gender affirming care coverage, exclusions, and whether Gender Affirming Care is a covered benefit under the member's plan prior to filing.

Submit unlisted CPT-coded services per the Unlisted Procedures Payment Policy.
Verify member-specific benefits, coverage, and exclusions before submission.
Do not use non-specific CPT codes (e.g., 55970, 55980) for pricing or claims processing; file with the specific procedure code when available.

Prior Authorization

Prior Authorization Per Member Plan

Verify prior authorization requirements and eligibility on a per-member basis: confirm the member has a documented diagnosis of gender dysphoria, has lived and worked full-time in a congruent gender role for at least 12 months, and that Gender Affirming Care is an included benefit in the member's plan. Prior authorization inquiries and determinations should reference the member's specific benefit booklet, Evidence of Coverage, or Subscriber Agreement.

Confirm diagnosis of gender dysphoria (filed as the primary ICD-10-CM diagnosis).
Confirm documentation of 12 months full-time congruent living/working.
Verify that Gender Affirming Care is a covered benefit in the member's plan and whether prior authorization is required.

Denial Risk

Denial Risk and Member Billing

Claims may be denied if services are not medically necessary or are non-covered benefits per the member's subscriber agreement. For member-specific coverage questions contact the provider call center. Providers may not balance-bill members for services determined to be non-covered or not medically necessary unless the member was informed and provided written consent to proceed at their own expense.

Denials can occur when eligibility criteria are not met or when Gender Affirming Care is excluded from the member's plan.
Contact the provider call center for member-specific benefit verification.
Obtain written member consent before billing members for non-covered services.