CurrentCignaPolicy N/A

Gender Dysphoria Treatment (State-Specific Coverage)

This document describes Cigna's state-specific requirements and exemptions for coverage and utilization management of gender dysphoria treatment (including gender-affirming surgeries and related services) and identifies states where utilization management is exempt or where specific coverage rules apply.

Policy Summary

PayerCigna

PolicyGender Dysphoria Treatment (State-Specific Coverage)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date8/18/2025

Next Review DateN/A

Key ActionFollow state-specific prior authorization and medical necessity processes and submit documentation for case-by-case review where required (e.g., Washington, Colorado).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3states explicitly listed as exempt from utilization management

multiplestates with specific coverage/requirement notes included

8/18/2025effective date shown at document header

eightelectrolysis daily timed-unit limit noted for Colorado

State-specific Coverage Criteria

Colorado - Medically necessary procedure classification

Covered when classified as medically necessary by state-regulated EHB plans (Colorado example):

Colorado EHB classification: The listed feminization/masculinization procedures (with specified CPT/HCPCS codes) are classified as medically necessary for coverage under the Essential Health Benefits (EHB) benefit plan effective 1/1/2023.

Applies to regulated plans with EHB (e.g., individual, non‑grandfathered small group).

Washington - No blanket exclusions; case review required

For Washington regulated benefit plans:

WA case-by-case review: Facial feminization surgeries and other facial gender‑affirming treatments (for example, tracheal shaves, hair electrolysis), mastectomies, breast reductions, breast implants, revisions, and any combination of gender‑affirming procedures cannot be subject to a blanket exclusion and will be reviewed on a case‑by‑case basis by a medical director and a health care provider experienced in gender‑affirming care to confirm the appropriateness of any adverse benefit determination.

Policy Summary

PayerCigna

PolicyGender Dysphoria Treatment (State-Specific Coverage)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date8/18/2025

Next Review DateN/A

Key ActionFollow state-specific prior authorization and medical necessity processes and submit documentation for case-by-case review where required (e.g., Washington, Colorado).

SourceLink

On This Page

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Provider Requirements and Prior Authorization

Prior Authorization

State-specific prior authorization and medical necessity review

Some states require prior authorization or medical necessity review for gender-affirming treatments and related procedures. Check applicable state mandates and plan type (self-funded vs. fully insured) before submitting requests.

States with full exemptions from utilization management for gender dysphoria treatment include: California (effective 10/25/2023), New York (effective 8/18/2025), and Oregon (effective 1/31/2025).
Regulated benefit plans in many states may have specific mandated coverage/classification for feminization/masculinization procedures; confirm state requirements prior to authorization.

Note

Provider Actions

Providers should follow state-specific requirements, obtain and include required documentation, and submit prior authorization requests when applicable. Ensure letters of support, operative reports, and records of prior treatments are included as required by the member's state and plan.

Include applicable CPT/HCPCS and relevant clinical documentation.
For minors and other special populations, follow state-mandated documentation rules (e.g., Virginia: only one letter of support required for minors where applicable).

Documentation Required

Documentation for WA case review

For Washington State regulated plans, case-by-case reviews require documentation sufficient for clinical review by a medical director and a health care provider experienced in gender-affirming care. Include detailed clinical rationale, prior treatment history, and any supporting specialty evaluations.

Document the specific procedures requested, clinical indications, prior treatments and outcomes, and any prior authorizations or revisions.
Attach letters of support, mental health evaluations when applicable, and operative/consultation notes to facilitate the case review.

Denial Risk

Case-by-case review required in WA

Washington State: facial feminization surgeries and other facial gender-affirming treatments (including tracheal shave, hair electrolysis), mastectomies, breast reductions, breast implants, combinations of gender-affirming procedures, and revisions cannot be subject to a blanket exclusion. All such services must be reviewed on a case-by-case basis by a medical director and a clinician experienced in gender-affirming care to determine appropriateness of any adverse benefit determination.

This requirement applies to regulated benefit plans in Washington.
Do not issue blanket denials; route requests for these services for individualized clinical review.

Background and Scope

This document addresses state-specific coverage, definitions, and utilization management rules for treatment of gender dysphoria and related gender-affirming care. It distinguishes covered gender-affirming services (including prescribing or administering puberty blockers and cross-sex hormones, and performing gender reassignment surgeries) from services that are not considered gender transition procedures (for example, care for persons with a medically verifiable disorder of sex development). The policy also identifies state requirements and exemptions — for instance, certain procedures are classified as medically necessary under Colorado-regulated EHB plans and Mississippi prohibits coverage of gender transition procedures for individuals under 18 years of age — and notes that state-specific prior authorization and medical-director review processes may apply where mandated.

Definitions

inv-13: Gender transition / Gender transition procedures

Definition'Gender transition' means the process in which a person goes from identifying with and living as a gender that corresponds to his or her sex to identifying with and living as a gender different from his or her sex; it may involve social, legal, or physical changes.

IncludesPrescribing or administering puberty‑blocking drugs, prescribing or administering cross‑sex hormones, and performing gender reassignment surgeries.

PurposeServices are performed for the purpose of assisting an individual with a gender transition.

inv-14: Exclusions related to disorders of sex development

Scope exclusion'Gender transition procedures' do not include services to persons born with a medically verifiable disorder of sex development (DSD).

Examples of DSDConditions such as 46,XX with virilization; 46,XY with undervirilization; or individuals with both ovarian and testicular tissue.

Clinical confirmationExcludes services provided when genetic or biochemical testing demonstrates atypical sex chromosome structure, sex steroid hormone production, or sex steroid hormone action.

15820	Blepharoplasty (eye and lid modification)
15821	Blepharoplasty
15822	Blepharoplasty
15823	Blepharoplasty
15824	Rhytidectomy / Face/forehead and/or neck tightening
15825	Rhytidectomy / Face/forehead and/or neck tightening
15826	Rhytidectomy
15828	Rhytidectomy
21137	Face/forehead and/or neck tightening
21138	Face/forehead and/or neck tightening

OpenPayer

Gender Dysphoria Treatment (State-Specific Coverage)

State-specific Coverage Criteria

Codes and Limits

Provider Requirements and Prior Authorization

Background and Scope

Definitions