CurrentDevoted HealthPolicy UMGT.CL.0049

Gender-Affirming Care and Services

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This policy governs coverage of gender-affirming services and care for all Devoted plans. Hormone therapy is subject to the member’s prescription drug benefit and applicable prior authorization requirements, while surgical requests are evaluated case by case against medical necessity criteria.

Policy Summary

PayerDevoted Health

PolicyGender-Affirming Care and Services

Policy CodePolicy UMGT.CL.0049

Change TypeNo material change

Effective DateJan 20, 2026

Last ReviewJan 12, 2026

Next Review DateJan 15, 2027

Key ActionSubmit surgical requests for case-by-case evaluation against the policy’s medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All plansPlan applicability

18 yearsMinimum surgical age

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CurrentDevoted HealthPolicy UMGT.CL.0049

Gender-Affirming Care and Services

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Policy Summary

PayerDevoted Health

PolicyGender-Affirming Care and Services

Policy CodePolicy UMGT.CL.0049

Change TypeNo material change

Effective DateJan 20, 2026

Last ReviewJan 12, 2026

Next Review DateJan 15, 2027

Key ActionSubmit surgical requests for case-by-case evaluation against the policy’s medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All plansPlan applicability

18 yearsMinimum surgical age

12 monthsPsychotherapy duration

12 monthsReal-life experience

12 monthsHormone therapy duration

15Excluded categories

Medical Necessity and Coverage Criteria

Surgical Treatment for Gender Dysphoria

Surgical treatment for gender dysphoria may be considered medically necessary when ALL of the following criteria are met:

Surgical medical necessity

Age and treatment plan
- Minimum age: The individual is at least 18 years of age.18 years
- Individualized treatment plan: A gender reassignment treatment plan is created specific to the individual beneficiary.
Documented DSM-5 diagnosis of gender dysphoria
- Gender incongruence and manifestations
  - At least 2 of the following manifestations
    A marked incongruence between one's experienced or expressed gender and primary and/or secondary sex characteristics.
    A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced or expressed gender.
    A strong desire for the primary and/or secondary sex characteristics of the other gender.
    A strong desire to be of the other gender, or some alternative gender different from the individual's assigned gender.
    A strong desire to be treated as the other gender, or some alternative gender different from the individual's assigned gender.
    A strong conviction that the individual has the typical feelings and reactions of the other gender, or some alternative gender different from the individual's assigned gender.
- Functional impact
  - The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Mental health documentation and real-life experience
- One letter from a mental health professional documents that the patient has had, at minimum, twelve months of psychotherapy sessions.At minimum 12 months
- The letter documents that any comorbid psychiatric or other medical conditions are stable and that the individual is prepared to undergo surgery.
- The letter documents that the patient has had persistent and chronic gender dysphoria.
- The letter documents that the patient has completed twelve months of continuous, full-time, real-life experience in the desired gender.12 months of continuous, full-time real-life experience
Additional treatment and surgical-readiness requirements
- If required by the mental health professional, the individual has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional.
- Unless medically contraindicated, or the individual is otherwise unable to take cross-sex hormones, documentation shows that the individual has participated in twelve consecutive months of cross-sex hormone therapy of the desired gender continuously and responsibly, including screenings and follow-ups with the professional provider.12 consecutive months when applicable
- The individual has knowledge of all practical aspects of the gender reassignment surgery, including required lengths of hospitalization, likely complications, and postsurgical rehabilitation.

Excluded procedures and services include liposuction, rhinoplasty, rhytidectomy (face lift), blepharoplasty, hair removal or hair transplantation, facial feminizing procedures such as facial bone reduction, chin augmentation, collagen injections, lip reduction or enhancement, cricothyroid approximation, trachea shave or reduction thyroid chondroplasty, laryngoplasty, and mastopexy (breast lift).

Diagnosis, Procedure, and Threshold Coding

ICD-10 Diagnosis CodesICD-10

F64.0-F64.9	Gender identity disorders and gender dysphoria
Z87.890	Personal history of sex reassignment

CPT CodeCPT

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
	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

1–10 of 49

1/5

Facial ProceduresCPTNot Covered

21137	Reduction forehead; contouring only
21209	Osteoplasty, Facial Bones; Reduction
21025	Excision of bone; mandible
30400 - 30420	Rhinoplasty; primary
30430 - 30450	Rhinoplasty; secondary
31599	Unlisted procedure, larynx [thyroid chondroplasty and tracheal shave] [voice modification surgery] [check benefits]
31899	Unlisted procedure, trachea, bronchi [Chondrolaryngoplasty, Adam's apple reduction, thyroid cartilage reduction]

Minimum age

Minimum ageAt least 18 years of age for surgical medical necessity criteria

Gender incongruence duration

Gender incongruence durationAt least 6 months

Psychotherapy duration

Psychotherapy durationAt minimum 12 months of psychotherapy sessions

Full-time real-life experience

Authorization, Documentation, and Review Actions

Prior Authorization

Hormone Therapy Authorization

Process gender-affirming hormone replacement therapy (HRT) requests under the member’s prescription drug benefit, including applicable gender-dysphoria prior authorization criteria for drugs on the plan formulary.

Part B drug requests follow the applicable Part B prior authorization process.
Part D drug requests follow the applicable Part D prior authorization process.

Documentation Required

Case-by-Case Surgical Review

Evaluate every request for gender-affirming surgical procedures on a case-by-case basis. Surgery may be considered medically necessary only when all applicable medical-necessity criteria are satisfied and the request is otherwise covered under the member’s plan.

Individual medical-necessity review is required for each surgical request.

Policy Background and Scope

This policy addresses gender-affirming hormone therapy and surgical procedures for members seeking care related to gender dysphoria or gender affirmation across all Devoted plans. Hormone replacement therapy is covered under the member’s prescription drug benefit and applicable prior authorization requirements, while surgical requests are evaluated individually against the policy’s medical necessity criteria.

Definitions and Abbreviations

CMS

CMSCenters for Medicare and Medicaid Services

HRT

HRTHormone Replacement Therapy

LCD

LCDLocal Coverage Determinations

MCD

MCDCMS Medicare Coverage Database

Policy Summary

PayerDevoted Health

PolicyGender-Affirming Care and Services

Policy CodePolicy UMGT.CL.0049

Change TypeNo material change

Effective DateJan 20, 2026

Last ReviewJan 12, 2026

Next Review DateJan 15, 2027

Key ActionSubmit surgical requests for case-by-case evaluation against the policy’s medical necessity criteria.

SourceLink

On This Page

Duration: The marked incongruence between the individual's experienced or expressed gender and assigned gender has been present for at least 6 months.At least 6 months

Full-time real-life experience12 months of continuous, full-time real-life experience in the desired gender

Cross-sex hormone therapy

Duration12 consecutive months of continuous and responsible cross-sex hormone therapy

ExceptionUnless medically contraindicated or the individual is otherwise unable to take cross-sex hormones

When criteria are met, listed procedures may be covered for gender-affirming care, subject to plan requirements.

Documentation Required

Diagnosis and Treatment Plan

Obtain an individualized gender reassignment treatment plan created specifically for the beneficiary, along with a documented DSM-5 diagnosis of gender dysphoria and supporting clinical history.

The diagnosis requires marked incongruence between experienced/expressed gender and assigned gender for at least 6 months, manifested by at least two specified DSM-5 features.
The condition must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Documentation Required

Mental Health Documentation

Collect a letter from a mental health professional documenting at least 12 months of psychotherapy and attesting to the required clinical findings and surgical preparedness.

Document that comorbid psychiatric or medical conditions are stable and that the individual is prepared for surgery.
Document persistent and chronic gender dysphoria.
Include related psychiatric documentation and psychotherapy participation during the real-life experience when required by the mental health professional.

Documentation Required

Treatment History and Surgical Readiness

Document the treatment history and readiness elements supporting surgery, including psychotherapy, real-life experience, hormone therapy when applicable, and knowledge of practical surgical requirements.

At least 12 months of continuous, full-time real-life experience in the desired gender is required.
Unless medically contraindicated or the individual is otherwise unable to take cross-sex hormones, document 12 consecutive months of continuous and responsible hormone therapy, including screenings and follow-ups.
Document psychotherapy throughout the real-life experience when required by the mental health professional, at a jointly determined frequency.
Document knowledge of hospitalization length, likely complications, and post-surgical rehabilitation.

Unsupported block type: denial_risk

Denial Risk

Surgical Criteria Not Met

Flag surgical requests for denial risk when any required medical-necessity criterion is absent or unsupported. The individual must be at least 18 years old and satisfy the individualized treatment-plan, DSM-5 diagnosis, psychotherapy, real-life experience, hormone-therapy, and readiness requirements, unless an applicable exception or contraindication is documented.

Deny or pend for documentation when the individual is under 18.
Deny or pend when an individualized gender reassignment treatment plan or documented DSM-5 gender dysphoria diagnosis is missing.
Deny or pend when the required 12 months of psychotherapy, continuous full-time real-life experience, or mental-health attestation is absent.
Deny or pend when required hormone-therapy history is absent without documented medical contraindication or inability to take cross-sex hormones.
Deny or pend when the individual’s surgical readiness, including understanding of practical surgical aspects, is not documented.

Denial Risk

Excluded Procedures

Do not treat the following procedures and services as covered gender-affirming surgical benefits; they are explicitly listed as exclusions.

Liposuction; rhinoplasty; rhytidectomy (face lift); blepharoplasty; hair removal or hair transplantation.
Facial feminizing procedures, including facial bone reduction; chin augmentation; collagen injections; lip reduction or enhancement; mastopexy (breast lift).
Cricothyroid approximation; trachea shave or reduction thyroid chondroplasty; laryngoplasty and other voice-modification procedures.

NCD

NCDNational Coverage Determination

UMUtilization Management