Gender Dysphoria Treatment
Defines Cigna's coverage policy for medical and surgical treatment of gender dysphoria, including behavioral health, hormonal therapy, laboratory monitoring, age-related preventive services, and gender reassignment surgeries; applies to health benefit plans administered by Cigna Companies.
Revised Table 2 to add soft tissue grafting (direct excision).
Moved submental skin/subcutaneous tissue excision from Table 3 to Table 2.
Added Appendix with state-specific information.
Updated information regarding New York fully insured plans being not subject to utilization management for gender dysphoria treatment (effective 8/18/2025).
Updated Note regarding Oregon insured plans being not subject to utilization management for gender dysphoria treatment (effective 1/31/2025).
For Virginia regulated insured plans: only one letter of support is required for gender-affirming surgery for minors ages 15-17.
Washington regulated plans cannot impose blanket exclusions on facial feminization and certain other gender-affirming procedures; such services must be reviewed case-by-case and are subject to mandated coverage criteria.
Coverage Criteria for Gender-Affirming Care
inv-01: Gender reassignment surgery — general medical necessity criteria
Gender reassignment surgery is considered medically necessary when the following criteria are met (examples vary by procedure and age):
inv-03: Hysterectomy, salpingo-oophorectomy, orchiectomy, and reconstructive genital surgery
Covered for individuals age 18 years or older when mental health recommendation is provided:
inv-04: Specific procedures considered medically necessary under standard benefit plan language
When the above criteria are met, the listed procedures and associated CPT/HCPCS codes in Table 1 are considered medically necessary unless specifically excluded by the member's benefit plan.
inv-05: Procedures Considered Medically Necessary when Policy Criteria Met
Considered medically necessary when criteria in the applicable policy statements listed above are met:
See code groups for full list.
inv-06: Generally Not Medically Necessary
Generally considered Not Medically Necessary when performed as a component of gender dysphoria treatment unless subject to a coverage mandate or specifically listed in the applicable benefit plan document.
See Table 2 listings and notes for per-plan exceptions and limitations.
inv-07: Services Not Covered
Not Covered even if benefits are available for gender dysphoria treatment:
Certain services are not covered when used for removal of excess skin/fat outside head/neck, for laser hair removal, buttock lift/gluteal augmentation, calf implants, or lip procedures unless otherwise specified.
inv-08: Behavioral health eligibility documentation
Covered when ALL of the following are met
Documentation supports eligibility for hormone and/or surgical therapy as required by the policy and benefit plan.
inv-09: Adolescent surgical criteria and preoperative requirements
Covered when ALL of the following are met
Multidisciplinary evaluation including pediatric endocrinologist for adolescents is recommended.
Endocrine clearance and collaboration with surgical team is recommended prior to irreversible procedures.
These contraindications affect suitability for hormone therapy and timing of surgery.
inv-10: Surgical procedures and coverage stance — examples of included procedures
Procedures described include (not exhaustive):
Mastectomy may be considered for adolescents when clinically appropriate and when documentation criteria are met.
Genital surgery is typically irreversible and requires a careful multidisciplinary diagnostic process.
Refer to benefit plan and Cigna policy for limitations and per-procedure criteria.
The procedures listed in Table 2 for head and/or neck feminization/masculinization are considered not medically necessary under standard benefit plan language. Some individual benefit plans, however, may expressly cover some or all of these services, so providers should confirm plan-specific terms and prior authorization requirements before submitting claims.
Specific procedures explicitly excluded from coverage as gender reassignment services include hair transplantation (e.g., punch grafts 15775, 15776), abdominoplasty/panniculectomy and excision of excess skin and fat for body areas other than the head or neck (e.g., 15830, 15847), and other listed procedures such as buttock lift/gluteal augmentation, calf implants, and laser hair removal. Electrolysis and other services are also listed with limits or exclusion notes in Tables 2 and 3; review the code lists and notes for procedure-specific restrictions.
Procedures that are performed primarily to achieve or reinforce culturally traditional male or female appearance characteristics may be considered not medically necessary when performed as part of gender reassignment surgery. Whether such services are covered depends on the member's applicable benefit plan; providers should consult the plan document and the policy tables for specific limitations and exceptions.
State regulatory provisions: in Mississippi, for regulated (insured) benefit plans, coverage for gender transition procedures for persons under age 18 is prohibited. The statute defines "gender transition procedures" and specifies exclusions; providers should follow state law and the member's benefit terms when evaluating coverage for minors.
The policy clarifies that services provided to individuals born with a medically verifiable disorder of sex development (D/SD) (for example, 46 XX with virilization, 46 XY with undervirilization, or true ovotesticular differences) are not considered gender transition procedures and therefore are treated under separate clinical indications rather than as gender-affirming care.
Services provided when a physician has diagnosed a disorder of sexual development that is confirmed by genetic or biochemical testing (demonstrating abnormal sex chromosome structure, sex steroid production, or sex steroid action) are explicitly excluded from the definition of "gender transition procedures." Such care is managed according to the underlying D/SD diagnosis rather than under gender dysphoria coverage rules.
Treatment of an infection, injury, disease, or disorder caused by or exacerbated by the performance of gender transition procedures is not considered a gender transition procedure under the statutory definition and is therefore excluded from classification as such; clinical management of complications should be billed and adjudicated under the appropriate diagnostic and procedure codes for the complication rather than as gender transition treatment.
The statutory definitions explicitly state that male circumcision procedures are not included in the definition of "gender transition procedures." Male circumcision is therefore not treated as a gender-affirming procedure under this policy or the cited state statute.
For reconstructive chest surgery, the policy specifies age-based coverage thresholds. Initial mastectomy for individuals age < 15 years is considered not medically necessary. For ages 15 to <17 years and ≥17 years, distinct documentation and mental health letter requirements apply; refer to the mastectomy criteria for details.
Many facial, head, and neck procedures and other cosmetic procedures listed in Table 2 are described as generally not medically necessary when performed as part of gender dysphoria treatment unless the applicable benefit plan expressly covers them or they meet plan-specific criteria. Providers should check the member's benefit document and the table notes for face/neck–limited exceptions and any state-specific rules.
The policy notes that procedures performed solely to improve or conform to culturally traditional appearance characteristics may be treated as not medically necessary when done in the context of gender reassignment surgery. Coverage depends on plan terms and the clinical justification provided; review the applicable benefit plan and policy tables for any permitted exceptions.
inv-22: Covered CPT/HCPCS Codes (selected from tables) — reference to code list
Reference list of covered CPT/HCPCS codes (selected from Table 1):
Coding Tables and Limits
| 55980 | Intersex surgery, female to male (may involve staged procedures to form a penis and scrotum; insertion of prostheses; closure of the vagina) |
| 57110 | Vaginectomy/colpectomy |
| 56625 | Vulvectomy |
| 55899 | Metoidioplasty / Phalloplasty (unlisted procedure) |
| 64856 | Phalloplasty — nerve procedure (nerve transposition) |
| 17380 | Electrolysis, limited to eight 30-minute timed units per day |
| 54400 | Penile prosthesis, non-inflatable |
| 54401 | Penile prosthesis, inflatable |
| 54405 | Surgical correction of malfunctioning penile prosthesis |
| C1813 | HCPCS for penile prosthesis component |
| 15820 | Blepharoplasty |
| 15821 | Blepharoplasty |
| 15822 | Blepharoplasty |
| 15823 | Blepharoplasty |
| 67900 | Brow lift/Repair of brow ptosis |
| 17999 | Cheek/malar implants (unlisted) |
| 21210 | Graft, bone; nasal, maxillary or malar areas / Chin/nose implant component |
| 21270 | Malar augmentation, prosthetic material |
| 30400 | Rhinoplasty, primary |
| 30410 | Rhinoplasty, primary complete |
| 15820 | Blepharoplasty, lower eyelid |
| 15821 | Blepharoplasty, lower eyelid with extensive herniated fat pad |
| 15822 | Blepharoplasty, upper eyelid |
| 15823 | Blepharoplasty, upper eyelid; with excessive skin weighting down lid |
| 67900 | Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) |
| 17999 | Unlisted procedure, skin, mucous membrane and subcutaneous tissue |
| 21210 | Graft, bone; nasal, maxillary or malar areas |
| 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 |
| 11960 | Insertion of tissue expander(s) for other than breast |
| 11970 | Replacement of tissue expander with permanent implant |
| 11971 | Removal of tissue expander without insertion of implant |
| 14041 | Adjacent tissue transfer or rearrangement |
| 14301 | Adjacent tissue transfer or rearrangement, any area; defect 30.1–60.0 sq cm |
| 14302 | Adjacent tissue transfer; each additional 30.0 sq cm |
| 15100 | Split-thickness autograft, trunk/arms/legs; first 100 sq cm or less |
| 15101 | Split-thickness autograft; each additional 100 sq cm |
| 15200 | Full thickness graft, free, trunk; 20 sq cm or less |
| 15201 | Full thickness graft, free; each additional 20 sq cm |
| C1813 | Prosthesis, penile, inflatable (HCPCS) |
| C2622 | Prosthesis, penile, non-inflatable (HCPCS) |
| L8600 | Implantable breast prosthesis (HCPCS) |
| C1789 | Prosthesis, breast (implantable) (HCPCS) |
| F64.0 | Transsexualism (ICD-10) |
| F64.1 | Dual role transvestism (ICD-10) |
| F64.2 | Gender identity disorder of childhood (ICD-10) |
| F64.8 | Other gender identity disorders (ICD-10) |
| F64.9 | Gender identity disorder, unspecified (ICD-10) |
| Z87.890 | Personal history of sex reassignment (ICD-10) |
| 15775 | Punch graft for hair transplant; 1 to 15 punch grafts |
| 15776 | Punch graft for hair transplant; more than 15 punch grafts |
| 15830 | Excision, excessive skin and subcutaneous tissue; abdomen (abdominoplasty) |
| 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 |
| 15839 | Excision, excessive skin and subcutaneous tissue; other area |
| 17380 | Electrolysis hair removal (limited to eight 30-minute timed units per day) |
Provider Actions, Authorization, and Documentation
Prior Authorization & Precertification
Conditions of coverage and/or prior authorization requirements may apply. Confirm precertification/prior authorization per the member's benefit plan before scheduling services.
- Prior authorization may be required — confirm precertification per benefit plan
Prior Authorization for Reconstructive/Gender‑Affirming Procedures
When policy criteria are met for certain reconstructive and gender-affirming procedure codes, prior authorization is required. Submit supporting documentation including covered diagnosis and procedure codes to avoid claim denials.
- Prior authorization required when policy criteria met for certain reconstructive and gender-affirming procedure codes
- Coding/claim mismatches may trigger denial — submit covered diagnosis and procedure codes per policy
Step Therapy
Step therapy: No specific step therapy requirements are specified in this portion of the policy. Providers should verify the member's plan for any plan-specific step therapy rules before initiating treatment.
- Step therapy — no step therapy requirements specified in this portion of the document
Washington — No Blanket Exclusions
Washington-regulated plans prohibit blanket exclusions of facial feminization and certain other gender-affirming procedures. Adverse determinations for these services must be reviewed case-by-case by a medical director and a provider experienced in gender‑affirming care.
- Prohibition on blanket step therapy/exclusion (WA) — case-by-case review required for certain procedures
- Restrictions on blanket exclusions (WA) — Washington-regulated plans prohibit blanket exclusions for facial feminization and several procedures
Background and Scope
Background: Gender dysphoria is described as a marked incongruence between an individual's experienced or expressed gender and their primary and/or secondary sex characteristics, associated with psychological distress. Treatment options span behavioral health interventions, monitored hormone therapy, age‑appropriate preventive services, laboratory monitoring, and, when criteria are met, gender reassignment surgeries. Coverage is subject to the policy's clinical criteria, documentation requirements, and any applicable state or plan-specific rules.
Definitions
Revision History and Policy Changes
Policy effective date updated to 2026-01-15.
Revised Table 2 to add soft tissue grafting (direct excision) and moved submental skin/subcutaneous tissue excision from Table 3 to Table 2.
New York: fully insured plans are not subject to utilization management for gender dysphoria treatment effective 2025-08-18.
Oregon: fully insured plans are not subject to utilization management for gender dysphoria treatment effective 2025-01-31.
Added Appendix with state-specific information for New York, Oregon, Virginia, and Washington.
Virginia: for regulated insured plans only one letter of support is required for gender-affirming surgery for minors ages 15–17.
Washington: regulated plans cannot impose blanket exclusions on facial feminization and certain other gender-affirming procedures; adverse determinations must be reviewed case-by-case by a medical director and an experienced provider.
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