Transgender Services
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This retired operating procedure governed coverage and prior authorization for transgender services (medical counseling, behavioral health, hormone therapy, and gender-affirming surgeries) when benefits exist in a member's contract; it applied to CareFirst members and providers submitting requests for authorization.
This Operating Procedure has been retired as of 02/01/2025 and is no longer scheduled for review.
Coverage Criteria
Coverage conditional on contract and medical necessity
Covered when ALL of the following are met:
Verify member contract and obtain prior authorization when benefits are present.
Coverage for transgender services is conditional on the member's contract and a CareFirst determination of medical necessity. Verify the member's contract for specific benefits before proceeding. When benefits for transgender services are included in the member's contract, CareFirst will provide coverage only for services it determines to be medically necessary.
Some procedures associated with gender reassignment surgery may be considered cosmetic in nature and therefore not medically necessary. Services explicitly excluded by the member's contract, as well as services determined by CareFirst to be not medically necessary, experimental/investigational, or cosmetic, are not covered.
Coding
| No codes listed |
Provider Actions & Authorization
Prior Authorization Required
Prior Authorization Required — Benefits must be verified and prior authorization obtained when member benefits include transgender-related services. Submit requests and supporting clinical documentation to the CareFirst Preservice Review Department for determination of appropriateness and medical necessity.
- Verify member benefits prior to requesting authorization.
- Send prior authorization requests and all supporting clinical documentation to CareFirst Preservice Review Department (address above).
Step Therapy
Step therapy — No step therapy requirements specified for this retired procedure. Check member contract and any applicable Medical Policy (CareFirst Medical Policy 7.01.123) for current utilization management rules.
- No specified step therapy requirements in this retired procedure.
- Refer to CareFirst Medical Policy 7.01.123 and member contract for any applicable step therapy or utilization management requirements.
Verification & Submission
Verification and submission — Verify member benefits before requesting authorization. Submit required documentation to the CareFirst Preservice Review Department using the contact information above.
- Confirm benefits and any exclusions (e.g., cosmetic, experimental/investigational) in the member's contract prior to authorization.
- Include clinical records that support medical necessity when submitting to Preservice Review.
Denial Triggers
Denial triggers — Services may be denied if determined to be not medically necessary, experimental or investigational, or cosmetic in nature. Check the member's contract and CareFirst medical policy for coverage determinations.
- Denials may occur for services deemed not medically necessary, experimental/investigational, or cosmetic.
- Review CareFirst Medical Policy 7.01.123 and the member's contract for covered indications and exclusions.
Background
Gender dysphoria is addressed through a range of interventions including changes in gender expression/role, psychotherapy, hormone therapy, and gender-affirming surgeries for primary and/or secondary sex characteristics. Treatment options and their sequence vary by individual; when benefits exist in the member's contract, CareFirst covers those transgender services it determines to be medically necessary.
Definitions
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