Obtain prior authorization per member benefit and use listed procedure codes

Prior authorization is required when the member's benefit plan requires it; the policy includes a referenced list of applicable CPT/HCPCS procedure codes for gender-affirming treatments that may require authorization.

• See policy code list for procedure codes that may require prior authorization.
• Listing of a code in the policy is for reference and does not guarantee coverage or payment.

Verify benefits and plan-specific prior authorization requirements

Verify the member-specific benefit plan to determine whether prior authorization is required and whether the specific surgical or ancillary service is covered; fully-insured state plans and plan documents may impose different coverage rules.

• Confirm coverage and prior authorization requirements against the member specific benefit plan document and applicable laws.
• For hormone therapy, see the Medical Benefit Drug Policy titled Gonadotropin Releasing Hormone Analogs as plan documents may impose limits.
• Fully-insured plans in certain states (e.g., NY, DC, CA, WA) may follow alternate policies—refer to Benefit Considerations.

Document multidisciplinary assessment, consent capacity, and parental consent for adolescents

For adolescents, document a multidisciplinary assessment, discussion of risks and benefits, assessment of decision-making capacity, and parental consent when required before surgical interventions; include fertility preservation counseling as applicable.

• Multidisciplinary team assessment (mental health, endocrinology, other specialists) is recommended.
• Document capacity to consent and parental consent where required by law or plan.
• Provide and document fertility preservation counseling prior to surgical interventions.

Recognize that prior authorization is determined by the member's benefit plan

This policy is guidance; prior authorization and coverage determinations are governed by the member's specific benefit plan and any tools the payer uses (e.g., InterQual). Always reference the member-specific plan to determine prior authorization rules.

• In the event of conflict, the member specific benefit plan document governs.
• UnitedHealthcare may use InterQual or other tools to assist in administering benefits.

Complete required preparatory steps; note cosmetic exclusions

Complete and document required preparatory steps before certain surgeries: 12 months continuous full‑time real‑life experience and 12 months continuous hormone therapy for genital procedures; 12 months continuous hormone therapy for breast augmentation; presurgical voice lessons and/or 6 months continuous hormone therapy for voice masculinization. Note that certain ancillary procedures are considered cosmetic and excluded.

• Genital surgery: ≥12 months continuous full‑time real‑life experience and ≥12 months continuous hormone therapy (unless contraindicated).
• Breast augmentation: continued Gender Dysphoria after 12 months continuous hormone therapy.
• Voice surgery: documentation of presurgical voice lessons/therapy and 6 months continuous hormone therapy for masculinization.
• Ancillary cosmetic procedures listed in the policy are not medically necessary when performed as part of gender-affirming surgery.

Follow drug policy and member plan for hormone therapy coverage

For hormone-related benefits and sequencing, refer to the Medical Benefit Drug Policy titled Gonadotropin Releasing Hormone Analogs and the member-specific plan for limits or coverage rules.

• Plan documents may impose sequencing or drug-specific requirements for hormone therapies.
• Refer to the named drug policy for GnRH analogs for coverage details.

Document phased care progression for adolescents

For adolescent care, document phased care: psychosocial support, puberty suppression where indicated, hormone therapy when appropriate, and evidence of prior phases before considering surgery; include documentation that guidelines recommending phased care were considered.

• Record psychosocial support and involvement of multidisciplinary team.
• Document puberty suppression and hormone therapy phases where provided and their durations.
• Show evidence of prior phases in the treatment plan before surgical requests for adolescents.

No policy-specified step therapy — follow member plan if applicable

No specific step therapy protocol is stated in the policy text; providers should follow the member-specific benefit plan for any step therapy requirements.

• If the member plan includes step therapy, the plan governs.
• Policy text explicitly provides no specific step therapy requirements in these sections.

Provide complete required clinical documentation supporting medical necessity

Supply complete clinical documentation to support medical necessity: evidence of persistent, well‑documented Gender Dysphoria (≥6 months), capacity to consent, age (≥18 for most surgeries), favorable psychosocial-behavioral evaluation, required Qualified Healthcare Professional assessments (one for breast/voice; two independent for genital surgery), documentation of real‑life experience and hormone therapy durations, and presurgical voice therapy where applicable.

• Duration of Gender Dysphoria: at least 6 months per DSM-5-TR.
• Qualified Healthcare Professional assessments: one for breast/voice procedures; two independent assessments for genital surgery.
• Document favorable psychosocial evaluation, capacity to consent, and member age (>=18 for most surgical treatments).
• Include documentation of required real‑life experience and hormone therapy durations and presurgical voice lessons if applicable.

Document diagnosis and reference member-specific benefit for coverage determination

Establish and document the accurate diagnosis of gender incongruence or Gender Dysphoria; benefit coverage is determined by the member-specific benefit plan and applicable laws.

• Use DSM-5-TR criteria to document persistent Gender Dysphoria.
• Reference the member specific benefit plan document to determine whether the diagnosed service is a covered benefit.

Document preoperative planning, hair‑removal strategy, and informed counseling

Include preoperative planning and counseling notes in the record: rationale for the chosen surgical technique, donor-site hair removal planning when hair-bearing flaps are used, and evidence that risks and potential complications were discussed and understood.

• Document hair-removal planning (laser/electrolysis) when indicated to reduce postoperative complications from hair-bearing flaps.
• Record counseling on heterogeneous outcomes and complication risks (e.g., neovaginal stenosis, fistula).
• Include rationale for chosen technique in preoperative notes.

Record preparatory steps and avoid billing for excluded cosmetic procedures

Document required preparatory steps and note that certain cosmetic services are excluded: record completion of real‑life experience, hormone therapy, and voice therapy where required; do not request coverage for ancillary cosmetic procedures listed as not medically necessary.

• Ensure records show ≥12 months real‑life experience and hormone therapy for genital surgery where applicable.
• Document presurgical voice lessons/therapy for voice modification procedures.
• Do not rely on coverage for ancillary cosmetic procedures listed as not medically necessary in the policy.

Document hormone therapy duration and follow drug/plan rules

Document hormone therapy history and refer to the GnRH Analogs drug policy and member plan for limits or sequencing; include dates and duration of continuous hormone therapy when asserting eligibility based on therapy duration.

• Record start/end dates and continuous duration of hormone therapy (e.g., 12 months for breast/genital procedures, 6 months for voice masculinization).
• Refer to the Medical Benefit Drug Policy titled Gonadotropin Releasing Hormone Analogs for coverage specifics.

Ensure records show completion of prior phases before adolescent surgery

For adolescents, document the phased-care approach in the medical record (psychosocial support, puberty suppression, hormones) and explicitly show prior phases were completed before surgery is considered.

• Include multidisciplinary team notes and evidence that hormonal and psychosocial phases were completed.
• Note that evidence for genital GAS in adolescents is limited; document rationale carefully if considering adolescent surgery.

Insufficient documentation may result in denial

If required documentation is missing or does not demonstrate that the member meets the Coverage Rationale, the request may be denied; lack of required records is a documented risk for denial.

• Incomplete clinical records that fail to show required durations, assessments, or Qualified Healthcare Professional evaluations can lead to denial.
• Coverage does not apply to members who do not meet the indications listed in the Coverage Rationale.

Mitigate variability-related denial risk with detailed technique and outcomes documentation

High variability in surgical techniques and complication reporting can affect outcome assessment; ensure detailed documentation of technique, complications counseling, and expected outcomes to reduce risk of denial related to variable evidence.

• Describe the specific surgical technique and perioperative planning to support medical necessity.
• Document counseling provided on heterogeneous outcomes and complication rates (e.g., neovaginal stenosis, fistula).