Colorado Rocky Mountain Health Plans Gender Reassignment Coverage Update

Coverage Criteria and Medicare Context

Coverage overview / CMS and LCD context

High-level coverage stance

CMS NCD stance: CMS determined no national coverage determination (NCD) is appropriate at this time for gender reassignment surgery; in the absence of an NCD, coverage determinations will be made by local Medicare Administrative Contractors (MACs) on a case-by-case basis.

LCD/LCA compliance: Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) exist; where applicable, compliance with those LCDs/LCAs is required and providers should refer to the table of specific LCDs/LCAs for guidance.

Application of Medicare and internal coverage criteria

Coverage determination approach

Medicare-guided then internal criteria: After checking the Medicare Coverage Database for any applicable NCD, LCD, or LCA, if none is found or if the Medicare guidance is flexible or silent, refer to this policy's Coverage Rationale; UnitedHealthcare will apply internal coverage criteria developed from current clinical evidence and widely used guidelines to determine medical necessity.

See Medicare source materials and Instructions for Use.

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.

Procedure, Diagnosis, and PCS Codes

Male to Female (selected codes)CPT

19325	Breast augmentation with implant.
54125	Amputation of penis; complete.
54520	Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach.
54690	Laparoscopy, surgical; orchiectomy.
55866	Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed.
55970	Intersex surgery; male to female.
56800	Plastic repair of introitus.
56805	Clitoroplasty for intersex state.
57291	Construction of artificial vagina; without graft.
57292	Construction of artificial vagina; with graft.

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Female to Male (selected codes)CPT

19303	Mastectomy, simple, complete.
53420	Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage.
53425	Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage.
54660	Insertion of testicular prosthesis (separate procedure).
55175	Scrotoplasty; simple.
55180	Scrotoplasty; complicated.
55980	Intersex surgery; female to male.
56625	Vulvectomy simple; complete.
57106	Vaginectomy, partial removal of vaginal wall.
57110	Vaginectomy, complete removal of vaginal wall.

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Other ancillary services (selected)CPT

15771	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate.
15772	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof.
17380	Electrolysis epilation, each 30 minutes.
19316	Mastopexy.
19318	Breast reduction.
19350	Nipple/areola reconstruction.
30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip.
31599	Unlisted procedure, larynx.

ICD-10 Diagnosis CodesICD-10

F64.0	Transsexualism.
F64.1	Dual role transvestism.
F64.2	Gender identity disorder of childhood.
F64.8	Other gender identity disorders.
F64.9	Gender identity disorder, unspecified.
Z87.890	Personal history of sex reassignment.

ICD-10-PCS codes (selected)ICD-10

0U5J0ZZ	Destruction of clitoris, open approach.
0UB24ZZ	Excision of bilateral ovaries, percutaneous endoscopic approach.
0UT90ZZ	Resection of uterus, open approach.
0W4M070	Creation of vagina in male perineum with autologous tissue substitute, open approach.
0W4N071	Creation of penis in female perineum with autologous tissue substitute, open approach.

Applicable ICD-10-PCS Codes (group 1)ICD-10

0UT98ZZ	Resection of uterus, via natural or artificial opening endoscopic.
0UT9FZZ	Resection of uterus, via natural or artificial opening with percutaneous endoscopic assistance.
0UTC0ZZ	Resection of cervix, open approach.
0UTC4ZZ	Resection of cervix, percutaneous endoscopic approach.
0UTC7ZZ	Resection of cervix, via natural or artificial opening.
0UTC8ZZ	Resection of cervix, via natural or artificial opening endoscopic.
0UTG0ZZ	Resection of vagina, open approach.
0UTG4ZZ	Resection of vagina, percutaneous endoscopic approach.
0UTG7ZZ	Resection of vagina, via natural or artificial opening.
0UTG8ZZ	Resection of vagina, via natural or artificial opening endoscopic.

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Applicable ICD-10-PCS Codes (group 2)ICD-10

0VTS4ZZ	Resection of penis, percutaneous endoscopic approach.
0VTSXZZ	Resection of penis, external approach.
0VUS07Z	Supplement penis with autologous tissue substitute, open approach.
0VUS0JZ	Supplement penis with synthetic substitute, open approach.
0VUS0KZ	Supplement penis with nonautologous tissue substitute, open approach.
0VUS47Z	Supplement penis with autologous tissue substitute, percutaneous endoscopic approach.
0VUS4JZ	Supplement penis with synthetic substitute, percutaneous endoscopic approach.
0VUS4KZ	Supplement penis with nonautologous tissue substitute, percutaneous endoscopic approach.
0VUSX7Z	Supplement penis with autologous tissue substitute, external approach.
0VUSXJZ	Supplement penis with synthetic substitute, external approach.

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Code list completeness — ICD-10-PCS (chunks 18–19)

RequirementAll ICD-10-PCS codes explicitly listed in the Applicable Codes sections (chunks 18 and 19) must be used as applicable for billing and claims.

ScopeIncludes codes for resection, supplementation/replacement, and creation procedures for uterus, cervix, vagina, clitoris, vulva, testes, and penis as enumerated in chunks 18–19.

Usage guidanceUse the specific ICD-10-PCS code that matches the procedure approach and material (e.g., open, endoscopic, percutaneous endoscopic, external, autologous vs synthetic substitute) as listed in chunks 18–19.

Claim accuracySelect the most specific code from the listed ICD-10-PCS entries (chunks 18–19) to reflect approach and substitute type to support accurate claims and adjudication.

Provider Responsibilities, Prior Auth, and Billing

Prior Authorization

Key Provider Actions

The following are provider responsibilities and billing/prior authorization highlights. Providers must verify prior authorization requirements and member benefits before rendering services; code lists below are for reference only and do not guarantee coverage or payment.

Code listing is provided for reference — check prior authorization requirements and follow any applicable prior authorization process before providing services.
Coverage is contingent on the member-specific benefit plan document and applicable laws; inclusion of a code in this policy does not guarantee coverage or payment.
Providers are responsible for submission of accurate claims, retention of documentation, and compliance with documentation requests as needed to support medical necessity.
Step therapy: None specified in this policy. Providers should follow any plan-specific or delegated step therapy requirements and internal coverage criteria where applicable.

Key Definitions

Gender reassignment surgery — definition

DefinitionGender reassignment surgery: a general term to describe a surgery or surgeries that affirm a person's gender identity.

PurposeDescribes surgical procedures intended to align a person's physical characteristics with their gender identity.

ContextCMS has not issued a national coverage determination for gender reassignment surgery; local Medicare contractors may make case-by-case decisions (policy context referenced elsewhere).

FDA applicability for devices/instruments

Key pointFDA approval alone is not a basis for coverage; this section is informational only.

ApplicabilityMany gender reassignment surgical procedures are not subject to FDA approval, though devices and instruments used during procedures may require FDA approval.

Background and Policy Scope

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 History and Changes

2026-06-01code_removalLatest

Removed CPT code 15819 from Applicable Codes.

2026-06-01document_update

Updated list of documents available in the Medicare Coverage Database to reflect the most current information.

2026-06-01archival

Archived previous policy version MMP365.12.

OpenPayer

Gender Dysphoria and Gender Reassignment Surgery