The list of procedure and diagnosis codes included in this policy is provided for reference only. Listing of a code does not imply the service is covered or reimbursable; benefit coverage is determined by the member-specific benefit plan document and applicable laws. The inclusion of a code does not guarantee claim payment or reimbursement, and other policies or guidelines may apply when determining coverage.

When evaluating gender-affirming services, consider CMS guidance on cosmetic and related procedures. CMS Benefit Policy Manual Chapter 16, §120 identifies services considered cosmetic, and Chapter 16, §180 covers services that are related to or required as a result of services not covered under Medicare. Services that meet those CMS definitions should be considered exclusions when determining coverage under Medicare-based criteria and when applying member-specific benefit rules.

Refer to the CMS Claims Processing Manual for general rules on noncovered charges: Chapter 1, §60.1 provides information on how noncovered charges are defined and handled. Where a service is noncovered by Medicare or excluded by the member's benefit plan, claims should be processed in accordance with those noncovered charge provisions and applicable payer rules.

Gender reassignment surgery is a general term describing surgical procedures that affirm a person’s gender identity. CMS has not issued a national coverage determination for gender reassignment surgery; therefore, CMS has directed that local Medicare Administrative Contractors (MACs) make coverage determinations on a case-by-case basis. Where applicable, compliance with Local Coverage Determinations/Articles and CMS guidance (including considerations of cosmetic procedures per CMS Benefit Policy Manual Chapter 16) is required when applying Medicare-based coverage rules. Providers should check the Medicare Coverage Database for any relevant NCD, LCD, or LCA and follow member-specific benefit documents when determining coverage.

Policy revision effective June 1, 2026: Removed CPT code 15819 from the Applicable Codes. The Medicare-related documents listed in the policy were updated to reflect the most current information in the Medicare Coverage Database, and the previous policy version MMP365.12 was archived.