Centene gender-affirming procedures Coverage/Prior Auth

Coverage and Medical Necessity Criteria

General medical necessity for gender-affirming surgeries

Covered when ALL of the following are met:

Core diagnosis and eligibility: Member has gender dysphoria or gender incongruence per criteria: marked and sustained incongruence demonstrated by two or more indicators (e.g., incongruence with primary/secondary sex characteristics; strong desire to be rid of or to have characteristics of the other gender; desire to be or be treated as the other gender; conviction of typical feelings/reactions of the other gender) and associated functional impairment.two or more indicators

From I.A.

Capacity and health status: Member has capacity to make a fully informed decision and to consent; significant medical or mental health concerns, if present, are reasonably well controlled; other possible causes of apparent gender dysphoria/incongruence have been identified and excluded.N/A

From I.B.1–3.

Assessment and recommendation: At least one written, signed statement recommending gender-affirming medical or surgical treatment (GAMST) from a provider competent to independently assess and diagnose gender incongruence; the documented assessment identifies relevant mental/physical health conditions, discusses risks/benefits and reproductive effects/options.one written statement

From I.B.4 and I.B.5.ii

Age-specific additional requirements: For members ≥18: assessment by a qualified provider (licensed, minimum master's-level or equivalent), documentation of risks/benefits and reproductive discussion, and stability on gender-affirming hormones (which may include at least 6 months of hormone treatment unless hormone therapy is not desired or is medically contraindicated). For members <18: demonstrates emotional and cognitive maturity, has reached Tanner stage 2, informed reproductive discussion, and (unless not desired/contraindicated) a minimum of 12 months of hormone therapy for many procedures; assessments by appropriately qualified postgraduate-level providers are required.age dependent

From I.B.5.a–b and I.C.1–2

Procedure-specific coverage: Requested procedure is listed among gender-affirming surgeries considered medically necessary for the member's age group and meets any additional prerequisites (for example, assessment for breast cancer risk when mastectomy/augmentation requested); for adults at least 6 months of hormone therapy may be considered prior to some procedures as appropriate to goals.procedure listed

From I.C.1–2 and I.C.2.d,l,p

Facial procedures

Facial gender-affirming procedures are considered on a case-by-case basis when ALL of the following are met:

Base eligibility: All general criteria in sections I.A. (gender dysphoria/incongruence) and I.B. (eligibility) have been met.N/A

From II.A.

Intent and variation: Requested facial procedure is intended to correct an existing facial appearance that demonstrates significant variation from the standard appearance for the member's experienced gender.N/A

From II.B.

Adolescent hormone therapy: For members <18 years, 12 months of hormone therapy is required prior to facial surgery unless hormone therapy is not desired or is medically contraindicated.12 months

Revision procedures

Revision procedures are covered when ALL of the following are met:

Indication: Revision is required to address complications of a prior gender-affirming procedure (examples include wound dehiscence, fistula, chronic pain directly related to the prior surgery).complication-related

From III.

Criteria incorporating WPATH SOC-8 and eligibility notes

Policy criteria updated to align with WPATH SOC-8; intersex individuals are noted as exempt from some criteria.

Policy-level criteria: Criteria updated to incorporate WPATH Standards of Care version 8 (SOC-8). Individuals with a disorder of sexual development (intersex) are not required to meet the same criteria for duration of gender dysphoria, age requirements, or duration of prior treatment (such as hormone therapy); adolescent hormone-duration requirements (e.g., 12 months prior to mastectomy) should be considered on a case-by-case basis.

Reviewed by internal and external specialists; annual reviews documented.

Revisions and medically necessary revision procedures

Policy clarifies revision procedures coverage.

Revision procedures are medically necessary when performed to correct complications of a prior gender-affirming procedure; revisions performed solely for non-complication cosmetic reasons are not medically necessary.

Added/retained in revision history; cosmetic-only revisions excluded.

Procedures performed solely to improve appearance and that are unrelated to gender expression are considered cosmetic and are not medically necessary under this policy.

The policy explicitly states that procedures used only to improve appearance and unrelated to gender expression are not medically necessary; a previously published list of specific cosmetic procedures has been removed and replaced with this general exclusion.

Cosmetic procedures that are unrelated to gender expression are not medically necessary and therefore excluded from coverage under this clinical policy.

Revision procedures that are performed solely for non-complication cosmetic reasons are considered cosmetic and not medically necessary. By contrast, revisions that are required to correct complications of a prior gender-affirming procedure (for example, wound dehiscence, fistula, or chronic pain directly related to the surgery) may be considered medically necessary when supported by documentation.

Procedure and CPT Coding Guidance

CPT codes (partial list) - reconstructive/filler/expanderCPT

11950	Subcutaneous injection of filling material (eg, collagen)
11951	Subcutaneous injection of filling material (eg, collagen)
11952	Subcutaneous injection of filling material (eg, collagen)
11953	Subcutaneous injection of filling material (eg, collagen)
11954	Subcutaneous injection of filling material (eg, collagen)
11960	Insertion of tissue expander(s) for other than breast, including subsequent expansion
11970	Replacement of tissue expander with permanent implant
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

CPT codes (partial list) - grafts, flaps, dermabrasionCPT

15100	Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less
15101	Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm
15120	Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet
15200	Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less
15570	Formation of direct or tubed pedicle, with or without transfer; trunk
15757	Free skin flap with microvascular anastomosis
15780	Dermabrasion
15786	Abrasion; single lesion (eg, keratosis, scar)
15787	Abrasion; each additional 4 lesions or less

CPT codes (partial list) - mastectomy, augmentation, facial, genital reconstructiveCPT

17380	Electrolysis epilation, each 30 minutes
19303	Mastectomy, simple, complete
19325	Breast augmentation with implant
19350	Nipple/areola reconstruction
21120	Genioplasty; augmentation (autograft, allograft, prosthetic material)
21270	Malar augmentation, prosthetic material
30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
30410	Rhinoplasty, primary; complete, external parts including bony pyramid
30435	Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
53410	Urethroplasty, 1-stage reconstruction of male anterior urethra

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Facial/Head CPT CodesCPTCovered

21125	Augmentation, mandibular body or angle; prosthetic material.
21127	Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft).
21208	Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant).
21209	Osteoplasty, facial bones; reduction.
21210	Graft, bone; nasal, maxillary or malar areas (includes obtaining graft).
21270	Malar augmentation, prosthetic material.
30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip.
30410	Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip.
30420	Rhinoplasty, primary; including major septal repair.
30430	Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

Genitourinary and Related CPT CodesCPTCovered

30435	Rhinoplasty, secondary; intermediate revision (bony work with osteotomies).
30450	Rhinoplasty, secondary; major revision (nasal tip work and osteotomies).
31599	Unlisted procedure, larynx.
31899	Unlisted procedure, trachea, bronchi.
53410	Urethroplasty, 1-stage reconstruction of male anterior urethra.
53415	Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra.
53420	Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage.
53425	Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage.
53430	Urethroplasty reconstruction female urethra.
53460	Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type procedure).

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Additional Genital/Gonadal CPT CodesCPTCovered

54415	Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis.
54416	Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session.
54417	Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue.
54520	Orchiectomy, simple (including subcapsular) with or without testicular prosthesis, scrotal or inguinal approach.
54660	Insertion testicular prosthesis (separate procedure).
54690	Laparoscopy, surgical; orchiectomy.
55175	Scrotoplasty; simple.
55180	.
55970	Intersex surgery; male to female.
55980	Intersex surgery; female to male.

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Vaginal/Vaginoplasty CPT CodesCPTCovered

56805	Clitoroplasty for intersex state.
56810	Perineoplasty, repair of perineum, nonobstetrical (separate procedure).
57106	Vaginectomy, partial removal of vaginal wall.
57107	Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy).
57110	Vaginectomy complete removal vaginal wall.
57111	Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy).
57291	Construction artificial vagina; without graft.
57292	Construction artificial vagina; with graft.
57295	Revision (including removal) of prosthetic vaginal graft; vaginal approach.
57296	Revision (including removal) of prosthetic vaginal graft; open abdominal approach.

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Hysterectomy CPT CodesCPTCovered

58150	Total abdominal hysterectomy (corpus and cervix) with or without removal of tube(s), with or without removal of ovary(s).
58260	Vaginal hysterectomy, for uterus 250 g or less.
58262	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary (s).
58263	Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele.
58267	Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control.
58270	Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele.
58275	Vaginal hysterectomy, with total or partial vaginectomy.
58285	Vaginal hysterectomy, radical (Schauta type operation).
58290	Vaginal hysterectomy, for uterus greater than 250 g.
58291	Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).

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Laparoscopic Hysterectomy CPT CodesCPTCovered

58541	Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less.
58542	Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s).
58543	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g.
58544	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).
58550	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less.
58552	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary (s).
58553	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g.
58554	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).
58570	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less.
58571	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s).

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Ovarian/Adnexal CPT CodesCPTCovered

58661	Laparoscopy surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy).
58720	Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure).
58940	Oophorectomy, partial or total, unilateral or bilateral.
58999	Unlisted procedure, female genital system (nonobstetrical).

Other Relevant CPT CodesCPTCovered

64856	Suture of major peripheral nerve, arm or leg, except sciatic; including transposition.
64892	Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length.
64896	Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; more than 4 cm length.
67900	Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

inv-21: Hormone therapy duration — Adolescents: minimum 12 months for many surgeries; Adults: minimum 6 months may be considered

AdolescentsMinimum of 12 months of gender-affirming hormone therapy (or longer if required to achieve the desired surgical result) is required prior to many gender-affirming procedures (including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery) unless hormone therapy is not desired or is medically contraindicated.

AdultsAdults (≥18 years) are typically expected to remain stable on gender-affirming hormonal treatment, which may include at least 6 months of hormone treatment or longer if required to achieve the desired surgical result, unless hormone therapy is not desired or is medically contraindicated.

Procedure-specific noteFor certain procedures (e.g., gonadectomy/hysterectomy/salpingectomy/orchiectomy) at least six months of hormone therapy may be considered prior to the procedure, as appropriate for the member's goals.

Prior Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization is required for gender-affirming medical and surgical treatment (GAMST) per Health Plan rules. Providers must submit a signed written statement recommending GAMST from a qualified provider and include the documented assessment demonstrating that the member meets the policy's eligibility criteria (diagnosis of gender dysphoria/incongruence and the clinical eligibility elements).

Submit one written signed statement recommending GAMST from a qualified provider.
Include documented assessment identifying mental/physical health conditions, capacity to consent, discussion of fertility/reproductive options, and hormone therapy history when applicable.
Prior authorization applies to listed CPT and unlisted procedure codes associated with gender-affirming procedures.

Prior Authorization

Prior Authorization for Listed Codes

Prior authorization is required for the CPT and unlisted procedure codes associated with gender-affirming procedures. Verify code-level PA requirements with the Health Plan prior to scheduling.

Key Definitions and Qualifications

inv-33: Gender dysphoria / gender incongruence — definition and required indicators

DefinitionMarked and sustained incongruence between the member/enrollee's experienced/expressed gender and assigned gender, demonstrated by two or more listed indicators (e.g., marked incongruence with primary/secondary sex characteristics; strong desire to be rid of or to have the other gender's sex characteristics; strong desire to be treated as the other gender; conviction of typical feelings/reactions of the other gender) and associated impairment in functioning.

Required indicatorsPolicy requires at least two or more listed indicators to establish gender dysphoria/gender incongruence as part of medical necessity criteria.

Associated impactThe condition must be associated with impairment in social, occupational, or other important areas of functioning to meet the diagnosis criteria.

inv-34: Qualified assessor (adults) — provider qualifications for adult assessors

Minimum qualificationsProvider licensed by their statutory body and holding, at minimum, a master's degree in a clinical field related to transgender health or equivalent further clinical training and statutorily regulated; examples include mental health professionals, general medical practitioners, nurses, or other qualified health care providers.

Clinical Background

Gender dysphoria, or gender incongruence, refers to distress arising from a marked and sustained incongruence between an individual’s experienced or expressed gender and the sex assigned at birth. Treatment is individualized and may include psychotherapy, hormone therapy, and a range of gender-affirming medical and surgical interventions. This policy incorporates the World Professional Association for Transgender Health (WPATH) Standards of Care, version 8 (SOC-8), and recognizes that care pathways and eligibility criteria should be tailored to the individual, with special considerations for adolescents and for individuals with disorders of sex development (intersex).

OpenPayer

Clinical Policy: Gender-Affirming Procedures

Coverage and Medical Necessity Criteria

Procedure and CPT Coding Guidance

Prior Authorization, Documentation, and Provider Responsibilities

Key Definitions and Qualifications

Clinical Background