Prior Authorization

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products to determine member eligibility for services in this policy. See related policies for the Prior Authorization via Web-Based Tool for Procedures and drug prior authorization guidance.

• Prior authorization required for Medicare Advantage Plans; recommended for Commercial Products.
• See Related Policies: Prior Authorization via Web-Based Tool for Procedures; Prior Authorization of Drugs.

Prior Authorization and Eligibility

Prior authorization and documentation of eligibility are used to determine coverage. Failure to obtain prior authorization when required, or failure to document eligibility, may result in claim denial.

• Obtain prior authorization when required and document eligibility criteria.
• Missing prior authorization or eligibility documentation may lead to denial of services.

Eligibility Documentation

Members are eligible for gender affirming care services when documentation confirms both a diagnosis of gender dysphoria and that the member has lived and worked full-time in a congruent gender role for at least 12 months.

• Document diagnosis of gender dysphoria.
• Document at least 12 months of full-time living/working in a congruent gender role.

Claim Diagnosis Coding

Claims must be filed with an ICD-10-CM diagnosis code for gender dysphoria for services to qualify as gender affirming care under this policy. When the eligibility criteria are met and the service is filed for the purpose of gender affirming care with an appropriate gender dysphoria diagnosis code, additional medical necessity review may not be required for some services.

• File claims with an appropriate ICD-10-CM code for gender dysphoria as listed in the Coding section.

Hair Removal Claims Filing

To ensure correct claims processing, hair removal claims should be filed with specific CPT codes and an ICD-10-CM code for gender dysphoria when applicable.

• Electrolysis: 17380 — Electrolysis epilation, each 30 minutes
• Laser hair removal: use the specific laser CPT codes listed in the Coding section
• Hair removal may also be covered for donor-site preparation for phalloplasty or vaginoplasty when documented.

Hormone Trial for Breast Augmentation

For breast augmentation as gender affirming care, documentation that 12 months of hormone treatment did not produce sufficient breast enlargement may be required from the prescribing physician and the surgeon.

• For augmentation mammoplasty coverage, include documentation from the physician prescribing hormones and the surgeon confirming inadequate enlargement after 12 months of hormone therapy.

Prohibited Coding

Do not use CPT codes 55970 or 55980 for pricing or claims processing for services addressed in this policy. These unlisted/intersex procedure codes are not specific to the individual procedures covered here and should be replaced with the specific CPT codes for the performed procedure.

• 55970 Intersex surgery; male to female — do not use for pricing/processing
• 55980 Intersex surgery; female to male — do not use for pricing/processing
• Use the specific procedure CPT codes listed in the Coding section for claims.