Gender Dysphoria Treatment (Gender-Affirming) — Surgical and Related Treatments
Defines medical necessity criteria, covered and not medically necessary procedures, and applicable coding for surgical and ancillary treatments for gender dysphoria for Commercial and Individual Exchange plans (with state-specific exceptions). Affects providers performing gender-affirming surgery and utilization reviewers.
Added language to indicate this Medical Policy does not apply to the states of Florida and New Mexico; refer to the member specific benefit plan document.
Replaced permissive wording to require that individuals provide documentation that they meet all listed criteria for surgical treatment for Gender Dysphoria.
Revised coverage criteria for breast surgery to require individuals must be at least 18 years of age.
Revised list of ancillary procedures considered cosmetic and not medically necessary, adding clavicular shortening and rib reconstruction and updating wording for facial bone remodeling and pectoral implants.
Updated required medical record documentation to include the date and results of psychosocial-behavioral evaluation including management of coexisting mental health condition.
Added language for Fully-Insured Group Policies in New York Only requiring use of WPATH Standards of Care version 8 for utilization review.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.