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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyConnectiCare Gender Surgery Coverage | OpenPayer
    Ask Trek AI about this page
    ModifiedConnectiCarePolicy MG.MM.SU.28

    Gender-Affirming Surgery

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    This policy governs ConnectiCare coverage and prior authorization review for puberty suppression, cross-sex hormone therapy, gender-affirming genital and breast surgery, and related procedures. It applies to members requesting medically necessary treatment for gender dysphoria, subject to the member’s benefit plan and applicable legal requirements.

    Policy Summary
    PayerConnectiCare
    PolicyGender-Affirming Surgery
    Policy CodePolicy MG.MM.SU.28
    Change TypeModified
    Effective DateSeptember 11, 2026
    Next Review DateN/A
    Key ActionSubmit clinical evidence supporting the applicable medical-necessity criteria with every prior authorization request.
    SourceLink
    POLICY UPDATE CHANGES

    On May 17, 2024, case-by-case language was added for surgical revision requests.

    On July 14, 2023, the title and terminology were changed from gender affirming/reassignment surgery to gender affirming surgery, the appendix was updated from DSM-5 to DSM-5-TR, and coding was updated to correspond with the New York State Department of Health eMedNY Provider Manual.

    On November 12, 2021, CPT codes 11920, 11921, 11922, and 19350 were added as medically necessary services.

    On May 8, 2020, breast surgery prerequisites requiring a two-letter referral and living in the affirmed gender role for 12 months were eliminated.

    The policy title and terminology were changed from gender affirming/reassignment surgery to gender affirming surgery, replacing the term reassignment throughout the policy.

    CPT codes 11920, 11921, 11922, and 19350 were added as medically necessary services.

    Gluteal augmentation was added to the case-by-case review list.

    For breast surgery, the two-letter prerequisite and the prerequisite requiring members to live 12 months in the identified gender were eliminated.

    ConnectiCare adopted the clinical criteria of its parent corporation EmblemHealth and retired its prior policy.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    18+Standard minimum age for gender-affirming surgery coverage
    2Qualified licensed health professional letters generally required for surgery
    12 monthsMinimum hormone therapy period before genital surgery when applicable
    24 monthsMinimum hormone therapy period for medically necessary breast augmentation when breast growth is negligible
    4Explicitly excluded categories of reproductive-tissue, reversal, or sterilization-related services
    5Listed ICD-10 diagnosis codes

    Covered Services and Eligibility Criteria

    Puberty Suppression

    Puberty suppression is covered when ALL of the following requirements are met, based on a determination by a qualified medical professional that the member is eligible and ready for treatment:

    ALL of the following

    • Meets gender dysphoria diagnostic criteria.
    • Has experienced puberty to at least Tanner stage 2, with pubertal changes resulting in increased gender dysphoria.
    • Does not suffer from psychiatric comorbidity that interferes with diagnostic work-up or treatment.
    • Has adequate psychological and social support during treatment.
    • Demonstrates knowledge and understanding of expected treatment outcomes associated with pubertal suppressants and cross-sex hormones, as well as the medical and social risks and benefits of sex reassignment.

    Cross-Sex Hormone Therapy

    Cross-sex hormone therapy, including testosterone, testosterone cypionate, conjugated estrogen, and estradiol, is covered when the applicable age and medical-necessity requirements are met:

    ALL of the following

    • The member is 16 years of age or older.
    • A qualified medical professional has determined that treatment is medically necessary.

    • For members younger than 18

      • The member meets all Puberty Suppression criteria described above.
      • The member is 18 years of age or older.
    Requests for cross-sex hormones for members younger than 16 years of age are reviewed on a case-by-case basis.

    Case-by-Case Procedures

    The following services and procedures, including surgical revisions, are reviewed individually on a case-by-case basis rather than being automatically covered. The treating physician's letter of medical necessity must specifically document the clinical rationale for the requested procedure.

    ALL of the following

    • The requested service is one of the following: abdominoplasty; blepharoplasty; neck tightening or removal of redundant skin; breast, brow, face, or forehead lift; calf, cheek, chin, nose, or pectoral implant; collagen injection; drugs to promote hair growth or loss; gluteal augmentation; electrolysis unless required for vaginoplasty or phalloplasty; facial bone reconstruction, reduction, or sculpturing, including jaw shortening, or rhinoplasty; hair transplantation; lip reduction; liposuction; thyroid chondroplasty; voice therapy, voice lessons, or voice modification surgery.
    • The clinical rationale for the specific requested procedure is documented in the treating physician's letter of medical necessity.

    Cryopreservation, storage, and thawing of reproductive tissue, including all related services and charges, are excluded from coverage.

    Reversal of genital and/or breast surgery is excluded from coverage.

    Reversal of surgery to revise secondary sex characteristics is excluded from coverage.

    Reversal of any procedure resulting in sterilization is excluded from coverage.

    Coverage is not available for surgeries, services, or procedures that are purely cosmetic.

    A procedure is excluded when it is requested solely to enhance appearance rather than to medically treat the underlying gender dysphoria.

    Procedure, Diagnosis, and Threshold Coding

    Procedure CodesCPT
    11920Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less.
    11921Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm.
    11922Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof.
    11950Subcutaneous injection of filling material (eg, collagen); 1 cc or less.
    11951Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc.
    11952Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc.
    11954Subcutaneous injection of filling material (eg, collagen); over 10.0 cc.
    15769Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia).
    15771Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate.
    15772Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof.
    1–10 of 71
    1/8
    CPT Procedure CodesCPT
    40500Vermilionectomy (lip shave), with mucosal advancement.
    53430Urethroplasty, reconstruction of female urethra.
    54125Amputation of penis; complete.
    54400Insertion of penile prosthesis; non-inflatable (semi-rigid).
    54401Insertion of penile prosthesis; inflatable (self-contained).
    54405Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir.
    54408Repair of component(s) of a multi-component, inflatable penile prosthesis.
    54410Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session.
    54411Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue.
    54417Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session.
    1–10 of 72
    1/8
    Diagnosis CodesICD-10
    F64.0Transsexualism.
    F64.1Gender Dysphoria (ICD 10 Code Diagnosis: Dual-Role Transvestism).
    F64.8Other gender identity disorders.
    F64.9Gender identity disorder, unspecified.
    Z87.890Personal history of sex reassignment.
    Medically Necessary CPT Codes Added in Revision HistoryCPTCovered
    11920CPT code added as a medically necessary service
    11921CPT code added as a medically necessary service
    11922CPT code added as a medically necessary service
    19350CPT code added as a medically necessary service
    DSM-5-TR Diagnostic Codesmixed
    302.6 (F64.2)Gender Dysphoria in Children
    302.85 (F64.0)Gender Dysphoria in Adolescent and Adults
    255.2 (E25.)Congenital adrenal hyperplasia
    259.50 (E34.50)Androgen insensitivity syndrome
    302.6 (F64.8)Other Specified Gender Dysphoria
    302.6 (F64.9)Unspecified Gender Dysphoria
    Breast Augmentation Requirement
    ProcedureBreast augmentation
    Minimum hormone therapyAt least 24 months
    Growth requirementBreast growth must have been negligible during hormone therapy
    Cross-Sex Hormone Therapy
    TherapyCross-sex hormone therapy, including testosterone, cypionate, conjugated estrogen, and estradiol
    Minimum age16 years

    Authorization and Documentation Requirements

    Prior Authorization

    Submit Clinical Evidence With Prior Authorization

    The treating physician or primary care provider must submit clinical evidence showing that the patient meets the applicable treatment or surgical-procedure criteria. Submit this documentation with the prior-authorization request so ConnectiCare can review medical necessity and applicable benefit-plan provisions; the member’s benefit plan governs if it differs from this policy.

    • Include supporting clinical evidence and information for the requested service.
    • Medical necessity under the policy does not guarantee payment when the member’s benefit plan excludes the service.
    • Medicare coverage may also vary under applicable CMS NCDs, LCDs, or LMRPs.
    Documentation Required

    Provide Qualified-Provider Letters

    For gender-affirming surgery requests for members age 18 or older, submit referral letters from qualified licensed health professionals who independently assessed and are referring the member for surgery. Only one letter is required for breast surgery.

    Policy Scope and Clinical Context

    This policy addresses treatment for gender dysphoria and gender incongruence through puberty suppression, hormone therapy, and gender-affirming surgical procedures. Covered surgical categories include genital and breast procedures intended to alter morphology toward the physical appearance associated with the member’s gender identity. Medical and mental-health conditions must not contraindicate surgery or must be reasonably well controlled before surgery.

    Clinical and Identity Definitions

    Gender Dysphoria
    General meaningA general descriptive term for an individual’s discontent with the assigned gender
    Diagnostic useWhen used as a diagnosis, the term has a more specific definition
    Reference standardThe complete diagnostic definition is provided in the DSM-5-TR appendix
    Transgender
    ScopeA broad spectrum of individuals
    IdentityIndividuals who transiently or persistently identify with a gender different from their gender at birth
    Duration
    Policy Summary
    PayerConnectiCare
    PolicyGender-Affirming Surgery
    Policy CodePolicy MG.MM.SU.28
    Change TypeModified
    Effective DateSeptember 11, 2026
    Next Review DateN/A
    Key ActionSubmit clinical evidence supporting the applicable medical-necessity criteria with every prior authorization request.
    SourceLink
    On This Page
    Covered Services and Eligibility CriteriaProcedure, Diagnosis, and Threshold CodingAuthorization and Documentation RequirementsPolicy Scope and Clinical ContextClinical and Identity Definitions
    Medical necessityTreatment must be determined medically necessary by a qualified medical professional
    Gender-Affirming Surgery
    ServiceGender-affirming surgery
    Minimum age18 years
    Younger membersRequests for members under 18 years are reviewed case by case
    Hormone Therapy Before Genital Surgery
    Applicable procedureGenital surgery
    Minimum hormone therapyAt least 12 months before seeking genital surgery
    ExceptionsThe requirement does not apply when hormones are medically contraindicated or the member is otherwise unable to take them
    Gender-Role History Before Surgery
    RequirementLiving in a gender role congruent with the member’s gender identity
    Duration12 months
    ScopeIncludes binary and non-binary gender; mental-health counseling is required during that time when deemed medically necessary
    Duration of Gender Incongruence
    DurationAt least 6 months
    Applies toGender dysphoria in children, adolescents, and adults
    Clinical significanceThe condition must be associated with clinically significant distress or impairment in important areas of functioning
    Gender Dysphoria in Children
    Required symptomsAt least 6 of 8 specified symptoms
    Required criterionOne symptom must be Criterion A1: a strong desire to be the other gender or an alternative gender
    Functional impactThe condition must cause clinically significant distress or impairment in social, school, or other important areas of functioning
    Gender Dysphoria in Adolescents and Adults
    Required symptomsAt least 2 of 6 specified symptoms
    DurationAt least 6 months
    Functional impactThe condition must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
    • One letter must be from a psychiatrist, psychologist, psychiatric nurse practitioner, or licensed clinical social worker with an established and ongoing relationship with the member.
    • The second letter may be from a psychiatrist, psychologist, physician, psychiatric nurse practitioner, or licensed clinical social worker serving in an evaluative role.
    • Professionals must be licensed in New York for New York members or Connecticut for Connecticut members and act within their scope of practice.
    Prior Authorization

    Obtain Hormone Therapy Authorization

    Requests for puberty suppressants and cross-sex hormones require documentation of eligibility, readiness, and medical necessity as determined by a qualified medical professional. Cross-sex hormones are covered for members age 16 or older when medically necessary; requests for members younger than 16 are reviewed case by case.

    • For pubertal suppressants, document gender-dysphoria diagnostic criteria, puberty at least Tanner stage 2 with pubertal changes increasing dysphoria, and no psychiatric comorbidity interfering with work-up or treatment.
    • Document adequate psychological and social support and the member’s knowledge of expected outcomes, medical and social risks, and benefits of pubertal suppressants and cross-sex hormones.
    • Members younger than 18 receiving cross-sex hormones must meet the pubertal-suppressant eligibility criteria.
    Documentation Required

    Document Clinical Evidence for Review

    The treating physician or primary care provider must document the clinical evidence supporting the applicable treatment or diagnostic criteria for the requested service. The documentation should be sufficiently complete for ConnectiCare’s medical-necessity and prior-authorization review.

    • Apply the policy criteria to the specific treatment or surgical procedure requested.
    • Providers are expected to exercise independent medical judgment; the policy does not pre-empt clinical judgment or dictate practice.
    Documentation Required

    Submit Surgery Referral Documentation

    Referral letters for gender-affirming surgery must establish a persistent and well-documented case of gender dysphoria and address the other surgery-eligibility requirements. The letters must support the specific surgery being requested.

    • Document hormone therapy appropriate to the member’s gender goals for at least 12 months before genital surgery, unless medically contraindicated or the member is otherwise unable to take hormones; hormone therapy is not a prerequisite for mastectomy.
    • Document living for 12 months in a gender role congruent with the member’s gender identity, including binary and nonbinary identities, and mental-health counseling during that period when medically necessary; this is not required for breast surgery.
    • Document that contraindicating medical or mental-health conditions are absent or reasonably well controlled and that the member has capacity to make fully informed decisions and consent.
    Documentation Required

    Document the Medical Necessity Rationale

    For procedures reviewed case by case, the treating physician must provide a letter of medical necessity that specifically documents the clinical rationale for each requested procedure, including revisions.

    • Address why the requested procedure is medically necessary to treat the underlying gender dysphoria or otherwise meets the policy’s coverage requirements.
    • This requirement applies to ancillary procedures such as facial procedures, body contouring, implants, hair procedures, electrolysis, voice services, and related services.

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Unsupported block type: prior_auth

    The identification may be transient or persistent
    Transsexual
    DefinitionAn individual who seeks or has undergone social transition from male to female or female to male
    Hormone treatmentThe transition may involve cross-sex hormone treatment
    Surgical treatmentThe transition may involve genital surgery
    Hormone Therapy
    PurposeTo produce somatic changes that more closely approximate the physical appearance of the genotypically other sex
    AndrogensAdministered to genotypic and phenotypic females
    Estrogen or progesteroneAdministered to genotypic or phenotypic males; hormones may also be used for pubertal suppression
    Gender-Affirming Genital Surgery
    DefinitionGenital surgery that alters morphology to approximate the physical appearance of the genetically other sex
    Included proceduresThe policy’s listed genital procedures include procedures such as vaginoplasty, phalloplasty, orchiectomy, and urethroplasty
    ExclusionThe category excludes procedures performed for a diagnosable birth defect or other medically defined pathology, except gender dysphoria
    Gender Non-Conforming
    Alternate termAlso referred to as non-binary
    MeaningDescribes the extent to which a person’s gender identity, role, or expression differs from cultural norms associated with a particular sex
    Areas of differenceThe difference may involve gender identity, gender role, or gender expression
    Non-Binary
    IdentityAn identity that does not exist as a male/female dichotomy
    Possible identificationAn individual may identify as belonging to neither the male nor female genders
    Pronouns and terminologyIndividuals may use they/them pronouns and may identify as gender non-conforming
    Gender Dysphoria in Children
    Diagnostic definitionA marked incongruence between experienced or expressed gender and assigned gender lasting at least 6 months
    Symptom requirementAt least 6 of 8 specified symptoms must be present, including Criterion A1
    Functional impactThe condition must cause clinically significant distress or impairment in social, school, or other important areas of functioning
    Gender Dysphoria in Adolescents and Adults
    Diagnostic definitionA marked incongruence between experienced or expressed gender and assigned gender lasting at least 6 months
    Symptom requirementAt least 2 of 6 specified symptoms must be present
    Functional impactThe condition must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
    Posttransition
    Living statusThe individual has transitioned to full-time living in the desired gender, with or without legalization of gender change
    Treatment statusThe individual has undergone or is preparing to undergo at least one cross-sex medical procedure or treatment regimen
    Continuing treatmentThe specifier may be used for continuing procedures that support the new gender assignment
    Other Specified Gender Dysphoria
    PresentationSymptoms characteristic of gender dysphoria causing clinically significant distress or impairment predominate
    Diagnostic statusThe presentation does not meet the full criteria for gender dysphoria
    Clinical documentationThe clinician records the specific reason the full criteria are not met, such as duration of less than 6 months
    Unspecified Gender Dysphoria
    PresentationSymptoms characteristic of gender dysphoria causing clinically significant distress or impairment predominate
    Diagnostic statusThe presentation does not meet the full criteria for gender dysphoria
    Reason not specifiedThe clinician does not specify why the criteria are not met, or there is insufficient information for a more specific diagnosis