Cigna Gender‑Affirming Care Coverage Update

Coverage Criteria

inv-01: Gender Reassignment Surgery — Medical Necessity Criteria

Gender reassignment surgery is considered medically necessary when the following age- and documentation-based criteria are met for the specified procedures.

Reconstructive chest surgery (initial mastectomy): For initial mastectomy: if age >=17 then ONE letter of support from a qualified mental health professional who has evaluated the individual for gender dysphoria and gives unequivocal support for the proposed procedure; if age 15 to <17 then BOTH parental/guardian consent (when applicable) AND TWO separate letters from independent mental health providers experienced in adolescent mental health and childhood gender dysphoria, each confirming diagnosis, that it is marked and sustained over time (e.g., two years), addressing comorbidities, and documenting emotional and cognitive maturity necessary to provide informed consent; initial mastectomy for individuals <15 years is considered not medically necessary.age-specific

Letters must be from qualified/experienced mental health professionals as specified.

Breast augmentation: For breast augmentation: individual must be age >=18 and have ONE letter of support from a qualified mental health professional who has evaluated the individual for gender dysphoria and gives unequivocal support for the proposed procedure.age >=18

Hysterectomy / salpingo-oophorectomy / orchiectomy: For hysterectomy, salpingo-oophorectomy, or orchiectomy: individual must be age >=18 and have a recommendation/clearance for sex reassignment surgery from a qualified mental health professional who has evaluated the individual for gender dysphoria and gives unequivocal clearance for the proposed procedure.age >=18

Reconstructive genital surgery: For reconstructive genital surgery: individual must be age >=18 and have a recommendation/clearance for sex reassignment surgery from a qualified mental health professional who has evaluated the individual for gender dysphoria and gives unequivocal clearance for the proposed procedure.age >=18

inv-02: Medically Necessary Procedures (conditional) — procedures listed are considered medically necessary when ALL applicable criteria are met

Procedures listed are considered medically necessary when ALL of the applicable policy statements' criteria are met

Medical necessity condition: The listed procedures are considered medically necessary only when the individual meets the applicable policy statements and documentation criteria referenced elsewhere in this policy (e.g., confirmed diagnosis of gender dysphoria, required behavioral health evaluations/letters, appropriate endocrine management, and other preoperative documentation).

See the behavioral health documentation, hormone therapy, and pre-surgical documentation requirements in the policy for specifics.

inv-03: Generally Not Medically Necessary Procedures (Table 2)

Generally Not Medically Necessary when performed as part of gender dysphoria treatment (unless plan-specific coverage mandate applies)

Not medically necessary condition: Procedures listed in Table 2 are generally considered Not Medically Necessary when performed as a component of gender dysphoria treatment unless expressly required by a coverage mandate or specifically listed as available in the applicable benefit plan document.

Examples include many cosmetic facial/body procedures (dermabrasion, chemical peels, rhytidectomy, liposuction/panniculectomy, grafting/fat grafting, selected implants) and certain autologous soft tissue grafting codes referenced in Table 2.

inv-04: Services Not Covered (Table 3)

Not covered even if benefits are available for gender dysphoria treatment

Not covered condition: Procedures listed in Table 3 are Not Covered irrespective of gender dysphoria treatment coverage; notes specify certain procedure-specific restrictions (for example, electrolysis epilation is not covered when not part of a covered facial feminization or genital reconstructive procedure, and removal of excess skin/fat is not covered when used for other than head or neck).

Refer to Table 3 and accompanying notes for full list and exceptions.

inv-05: Coverage criteria for hormonal therapy and gender-affirming surgery

Covered when ALL of the following are met

Multidisciplinary evaluation and accurate diagnosis: A careful, long-term diagnostic process with a multidisciplinary specialty approach (behavioral health, endocrine, surgical specialties) including an extensive case history and appropriate examinations must document a diagnosis of gender dysphoria prior to surgical interventions.

Behavioral health documentation should confirm diagnosis, informed decision-making capacity, address comorbidities, and document treatment rationale.

Age and puberty criteria: Adolescents receiving puberty suppression or related interventions must have reached at least Tanner stage 2; performing gender reassignment surgery prior to age 18 is generally not recommended, although mastectomy may be considered when clinically and developmentally appropriate with required documentation.Tanner >=2; age considerations per policy

For adolescents aged 15-17, support from two independent mental health providers is recommended for mastectomy; age thresholds for specific surgeries noted elsewhere.

Hormone therapy management:

inv-06: State-regulated plan rules (Oregon, Virginia, Washington)

State-specific regulated-plan coverage and administrative rules excerpted from the appendix:

Oregon insured plans: For fully insured plans in Oregon, utilization management does not apply to gender dysphoria treatment effective 1/31/2025.effective 1/31/2025

Prior authorization requirements tied to utilization management do not apply to fully insured Oregon plans; applies to regulated insured products.

Virginia insured minors: For regulated insured plans in Virginia, only one letter of support from a healthcare professional is required for gender-affirming surgery for minors ages 15-17.ages 15-17

This is the documentation requirement for surgical authorization under Virginia regulated plans.

Washington regulated plans: For Washington regulated benefit plans, facial feminization surgeries and other facial gender-affirming treatments (e.g., tracheal shaves, hair electrolysis) and combinations with other gender-affirming procedures cannot be subject to blanket exclusions; such services will be reviewed case-by-case by a medical director and a provider experienced in gender-affirming care.

Head and/or neck feminization and masculinization procedures listed in Table 2 are treated as not medically necessary under standard benefit plan language unless the applicable benefit plan document expressly provides coverage. Table 2 includes a broad set of facial and neck procedures (e.g., blepharoplasty, rhytidectomy/neck tightening, submental excision, soft tissue grafting, dermabrasion/chemical peels, fat grafting) that are generally excluded from routine coverage for gender dysphoria treatment unless the member’s plan specifically lists them as covered or state-specific rules require otherwise.

Before approving any head/neck procedures for gender-affirming care, verify the member’s specific benefit plan and any applicable state-regulated plan requirements in the Appendix; some plans or state mandates may modify the Table 2 designation and permit coverage for some or all listed procedures.

Electrolysis (hair epilation) is addressed with specific limits: electrolysis related to gender-affirming procedures is only covered when it is part of a covered facial feminization procedure or a genital reconstructive procedure. Outside of those circumstances, electrolysis epilation is not covered and is generally considered not medically necessary.

When electrolysis is performed in conjunction with covered reconstructive procedures, timed-unit limits apply: electrolysis services are limited to eight 30-minute timed units per day when used for donor-site tissue preparation or lining of the vaginal canal (see Table notes). Care teams should document the medical necessity and relation to the covered procedure when submitting prior authorization requests or claims.

Some procedures performed as part of gender reassignment surgery are intended to assist with achieving culturally traditional male or female appearance characteristics. When such procedures are aimed primarily at cultural or social appearance norms rather than addressing the medical diagnosis of gender dysphoria, they may be considered not medically necessary for the purposes of coverage.

Coverage for procedures performed to achieve culturally traditional appearance should be determined by reference to the member’s benefit plan terms and any applicable state-specific requirements; the policy advises reviewing the applicable benefit plan document for limits and exclusions.

Mississippi state law prohibits coverage of gender transition procedures for persons under age 18 for regulated (insured) plans. For regulated plans in Mississippi, gender transition services (including prescribing puberty blockers, cross-sex hormones, or performing gender reassignment surgeries) are not covered for individuals under 18 as specified by statute.

Providers and administrators should confirm coverage applicability for members in Mississippi by checking the member’s plan type (regulated/insured) and applying the statutory prohibition when determining eligibility for gender-affirming services for minors.

Washington state rules for regulated (insured) plans prohibit blanket exclusions for facial feminization surgeries and other facial gender-affirming treatments, as well as combinations of gender-affirming procedures. Such services cannot be categorically excluded; instead, any adverse benefit determination must be reviewed on an individualized basis by a medical director and a provider experienced in gender-affirming care.

For members covered under Washington regulated plans, submit comprehensive documentation for case-by-case review rather than relying on categorical exclusions; the medical director review process will confirm whether the service is appropriate under mandated coverage criteria.

Initial mastectomy as part of gender reassignment surgery is subject to specific age-based documentation requirements. An initial mastectomy for an individual < age 15 years is considered not medically necessary under this policy.

For older adolescents and adults, the policy specifies differing documentation thresholds (e.g., one letter of support for age ≥17, two independent adolescent mental health evaluations plus parental/guardian consent for ages 15 to <17); follow the criteria in the Gender Reassignment Surgery section when requesting authorization.

Many reconstructive and aesthetic procedures listed in Table 2 (for example, injectable fillers, fat grafting, dermabrasion, chemical peels, blepharoplasty, rhytidectomy, subcutaneous fat removal, and various soft tissue grafting codes) are generally not medically necessary when performed as components of gender reassignment surgery unless the applicable benefit plan explicitly provides coverage or a state mandate requires coverage.

Table notes identify specific exceptions and limits (for example, allowance when procedures are limited to the face and neck and when plan language permits), and also specify timed-unit limits for certain services such as electrolysis; verify plan-level coverage and apply Table 2 designations when evaluating prior authorization requests or claims.

Procedures performed solely to improve culturally traditional appearance characteristics — such as interventions primarily intended to produce socially normative masculine or feminine traits — may be considered not medically necessary when done as part of gender reassignment surgery. Determinations depend on the clinical documentation and the member’s benefit plan language.

When cultural or aesthetic goals are primary to a requested procedure, examiners should refer to the member’s plan terms and the policy guidance that certain appearance-focused interventions may be excluded or limited under the plan.

This policy underwent multiple focused and annual reviews noted in the revision history. Several review entries state No clinical policy statement changes on the listed review dates, and the Annual Review (1/15/2026) documents operational updates to the tables (for example, adding soft tissue grafting and reclassifying submental excision between tables).

Operational table and coding updates are reflected in the revised tables and should be applied when coding and adjudicating claims, but these administrative changes did not introduce new clinical coverage statements beyond the clarified table assignments.

Coding and Procedure Codes

Covered CPT/HCPCS codes (selected examples from Tables 1 and code lists)mixedCovered

55980	Intersex surgery, female to male
57110	Vaginectomy/colpectomy
56625	Vulvectomy
55899	Metoidioplasty (unlisted male genital procedure)
64856	Nerve transposition (listed with phalloplasty)
17380	Electrolysis epilation, each 30 minutes
54400	Insertion of penile prosthesis; non-inflatable
54401	Insertion of penile prosthesis; inflatable
54405	Insertion of multi-component inflatable penile prosthesis
C1813	Penile prosthesis HCPCS (example listed)

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Other procedures / not medically necessary lists (selected)mixed

15820	Blepharoplasty
67900	Brow lift
17999	Unlisted procedure (used for some implants/transplants)
21210	Chin/nose implant / rhinoplasty-related code
30400	Rhinoplasty
17380	Electrolysis (not medically necessary for head/neck when not donor-site related)
15847	Abdominoplasty (listed as not covered)

Considered Medically Necessary (selected codes)CPTCovered

11960	Insertion of tissue expander(s) for other than breast, including subsequent expansion.
11970	Replacement of tissue expander with permanent implant.
11971	Removal of tissue expander without insertion of implant.
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.
14301	Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.
14302	Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof.
15100	Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children.
15101	Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children.
15200	Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less.

Considered Medically Necessary (continued)CPTCovered

15201	Full thickness graft, free; each additional 20 sq cm.
15738	Muscle, myocutaneous, or fasciocutaneous flap; lower extremity.
15757	Free skin flap with microvascular anastomosis.
17380	Electrolysis epilation, each 30 minutes.
17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue.
19303	Mastectomy, simple, complete.
19318	Breast reduction.
19350	Nipple/areola reconstruction.
53410	Urethroplasty, 1-stage reconstruction of male anterior urethra.
53430	Urethroplasty, reconstruction of female urethra.

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Considered Medically Necessary (gynecologic and related codes)CPTCovered

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).
58291	Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).
58552	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s).
58554	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).
58571	Laparoscopy, surgical; with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s).
58573	Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s).
58661	Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy).
64856	Suture of major peripheral nerve, arm or leg, except sciatic; including transposition.

HCPCS/HCPCS Level II prosthesis codesHCPCSCovered

C1813	Prosthesis, penile, inflatable.
C2622	Prosthesis, penile, non-inflatable.
L8600	Implantable breast prosthesis, silicone or equal.

Diagnosis and additional prosthesis codesmixed

C1789	Prosthesis, breast (implantable).
F64.0	Transsexualism.
F64.1	Dual role transvestism.
F64.2	Gender identity disorder of childhood.
F64.8	Other gender identity disorders.
F64.9	Gender identity disorder, unspecified.
Z87.890	Personal history of sex reassignment.

Table 2: Generally Not Medically Necessary (selected codes)CPTNot Covered

11950	Subcutaneous injection of filling material (eg, collagen); 1 cc or less.
11951	Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc.
11952	Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc.
11954	Subcutaneous injection of filling material (eg, collagen); over 10.0 cc.
15769	Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia).
15773	Grafting of autologous fat harvested by liposuction technique to face, etc.; 25 cc or less injectate.
15774	Each additional 25 cc injectate.
15780	Dermabrasion; total face.
15781	Dermabrasion; segmental, face.
15782	Dermabrasion; regional, other than face.

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Table 3: Services Not Covered (selected codes)CPTNot Covered

15775	Punch graft for hair transplant; 1 to 15 punch grafts.
15776	Punch graft for hair transplant; more than 15 punch grafts.
15825	Rhytidectomy; neck with platysmal tightening.
15830	Excision, excessive skin and subcutaneous tissue; abdomen (panniculectomy).
15832	Excision, excessive skin and subcutaneous tissue; thigh.
15833	Excision, excessive skin and subcutaneous tissue; leg.
15834	Excision, excessive skin and subcutaneous tissue; hip.
15835	Excision, excessive skin and subcutaneous tissue; buttock.
15836	Excision, excessive skin and subcutaneous tissue; arm.
15837	Excision, excessive skin and subcutaneous tissue; forearm or hand.

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Hormone therapy and related labsmixed

11980	Hormone therapy, listed
11983	Hormone therapy, listed
J1071	Hormone therapy, listed
J3121	Hormone therapy, listed
J3130	Hormone therapy, listed
J3490	Hormone therapy, listed
J1950	Hormone therapy, listed
J9217	Hormone therapy, listed
84402	Hormone laboratory testing
84403	Hormone laboratory testing

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Blepharoplasty codesCPT

15820	Blepharoplasty (eye and lid)
15821	Blepharoplasty (eye and lid)
15822	Blepharoplasty (eye and lid)
15823	Blepharoplasty (eye and lid)

Rhytidectomy / skin tightening codesCPT

15824	Face/forehead/neck skin tightening; rhytidectomy listed
15825	Face/forehead/neck skin tightening; rhytidectomy listed
15826	Face/forehead/neck skin tightening; rhytidectomy listed
15828	Face/forehead/neck skin tightening; rhytidectomy listed
15829	Face/forehead/neck skin tightening; rhytidectomy listed

Facial skeletal codesCPT

21137	Facial bone remodeling
21138	Facial bone remodeling
21139	Facial bone remodeling
21141	Facial bone remodeling
21142	Facial bone remodeling
21143	Facial bone remodeling
21172	Orbital/orbital recontouring
21179	Orbital/orbital recontouring
21180	Orbital/orbital recontouring
21188	Facial bone remodeling

Breast/chest procedure codesmixed

11920	Breast/chest procedures
11921	Breast/chest procedures
15200	Breast/chest procedures
15201	Breast/chest procedures
15771	Breast/chest procedures
15772	Breast/chest procedures
17999	Unlisted procedure, used for various listed services
19303	Breast reconstruction/augmentation
19304	Breast reconstruction/augmentation
19318	Breast procedures

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Genital surgical and related procedure codesmixed

11960	Genital surgical procedures list
11970	Genital surgical procedures list
11971	Genital surgical procedures list
14041	Genital surgical procedures list
14301	Genital surgical procedures list
14302	Genital surgical procedures list
15100	Genital surgical procedures list
15101	Genital surgical procedures list
15240	Genital surgical procedures list
15241	Genital surgical procedures list

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Table updates impacting procedure codesmixed

affected codes

Table changes reference addition of soft tissue grafting (direct excision) and movement of submental skin/subcutaneous tissue excision between tables; specific CPT/HCPCS codes updated in tables (details in other document sections).

Age threshold for initial mastectomy — age guidance and letter requirements

Minimum age≥ 17 years for initial mastectomy

Documentation for ≥17One letter of support from a qualified mental health professional who evaluated the individual and gives unequivocal support

Age 15 to <17Parental/guardian consent plus two separate letters from independent mental health providers experienced in adolescent gender dysphoria (each confirming diagnosis, marked and sustained nature, comorbidities, and maturity)

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

Prior authorization / conditions of coverage — precertification and medical necessity must be met prior to service

Prior authorization and medical necessity must be met prior to services listed in this policy. Providers should obtain precertification when required by the member's benefit plan and submit documentation that demonstrates the requested service meets applicable medical necessity criteria.

Precertification/prior authorization requirements vary by plan — check the member's benefit document.
Claims submitted without covered diagnosis or procedure codes will be denied; coding must match covered services.

Prior Authorization

Prior authorization likely required for listed surgical/procedural codes

Prior authorization is likely required for many of the listed surgical and procedural CPT/HCPCS codes. Confirm prior authorization requirements with Cigna (or delegated vendor) before scheduling services.

Examples of commonly affected CPT codes include 11960, 11970, 11971, 14301, 15240, 19325, 19342, 53430, 55970, 56620, 57291, 57292, 57335, and others listed in the policy code sections.

Background

Gender dysphoria is characterized by marked incongruence between experienced/expressed gender and primary or secondary sex characteristics, producing significant distress. Treatment options include behavioral health support, hormone therapy with monitoring, and gender-affirming surgeries where clinically indicated.

Accurate diagnosis and a long-term, multidisciplinary evaluation (including mental health and endocrine assessment) are foundational to determining medical necessity for gender-affirming interventions; this policy’s criteria and documentation requirements align with established standards and referenced guidance.

Definitions

Gender dysphoria — definition per professional society

DefinitionGender dysphoria: psychological distress resulting from an incongruence between sex assigned at birth and one's gender identity (per American Psychiatric Association)

ScopeDescribed as marked incongruence between experienced/expressed gender and primary/secondary sex characteristics

RelevanceDiagnosis underpins eligibility for gender-affirming treatments and surgical consideration

Gender reassignment/confirmation/affirmation — definition of transition processes

DefinitionGender reassignment/confirmation/affirmation: processes an individual may undergo to transition to the desired gender identity (terms used interchangeably)

IncludesBehavioral health, hormone therapy, and surgical procedures to align physical characteristics with gender identity

OpenPayer

Gender Dysphoria Treatment (Gender-Affirming Care) — Coverage Criteria

Coverage Criteria

Coding and Procedure Codes

Provider Actions, Documentation, and Prior Authorization

Background

Definitions