CurrentExcellus Health Plan IncPolicy 3.01.22

Gender Affirming Behavioral Health and Medical Services

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Medical-necessity evaluation for behavioral health, primary, reproductive, preventive, and related services for individuals diagnosed with gender dysphoria across the lifespan, supporting individualized, multidisciplinary gender-affirming care.

Policy Summary

PayerExcellus Health Plan Inc

PolicyGender Affirming Behavioral Health and Medical Services

Policy CodePolicy 3.01.22

Change TypeAnnual review — no material changes

Effective DateAugust 20, 2026

Last ReviewAug 20, 2026

Next Review DateAugust 1, 2027

Key ActionConfirm that the member's product covers the specific service before applying medical policy criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All agesBehavioral health services age range

SOC-8WPATH Standards of Care

3Product categories addressed

UnchangedPolicy intent at annual review

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CurrentExcellus Health Plan IncPolicy 3.01.22

Gender Affirming Behavioral Health and Medical Services

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Sign up for excellus_health_plan_inc Policy 3.01.22 alerts

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Policy Summary

PayerExcellus Health Plan Inc

PolicyGender Affirming Behavioral Health and Medical Services

Policy CodePolicy 3.01.22

Change TypeAnnual review — no material changes

Effective DateAugust 20, 2026

Last ReviewAug 20, 2026

Next Review DateAugust 1, 2027

Key ActionConfirm that the member's product covers the specific service before applying medical policy criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All agesBehavioral health services age range

SOC-8WPATH Standards of Care

3Product categories addressed

UnchangedPolicy intent at annual review

Medical Necessity and Coverage Criteria

Behavioral health services

Behavioral health services for a diagnosis of gender dysphoria are considered medically appropriate when the applicable clinical circumstances are present.

Behavioral health services, including assessment, counseling, and psychotherapy, are medically appropriate for individuals of all ages with a diagnosis of gender dysphoria.

Higher-acuity or substance-use presentation

Higher level of care: A behavioral manifestation of gender dysphoria requires a higher level of care, such as acute admission for suicidal ideation and intent.
Use the appropriate InterQual guideline or Corporate Medical Policy.
Substance use disorder: A behavioral manifestation of gender dysphoria is a substance use disorder.
Use the NYS OASAS LOCADTR tool and ASAM criteria.

Primary, reproductive, preventive, and screening care

All gender- and age-specific services that are otherwise medically necessary are also considered medically necessary for individuals diagnosed with gender dysphoria.

Gender- and age-specific medically necessary services: Provide otherwise medically necessary comprehensive primary care, including recommended preventive care and laboratory monitoring of hormone levels during prescribed treatment at clinically recommended frequency; reproductive care, including obstetric/gynecologic evaluation and treatment such as contraception; and gynecological or urological cancer screening before, during, and ongoing after gender-affirming treatments.

The listed services remain subject to their ordinary medical-necessity requirements.

Treatment approach

Treatment should be individualized and gender affirming.

Person-centered treatment: Use a person-centered, inter- and multi-disciplinary approach to care, including communication and coordination as appropriate; psychotherapy should never aim to modify the individual's gender identity or expression.

Conversion and reparative therapy are described as ineffective and harmful and should not be used as treatment for gender dysphoria.

Regulatory coverage protection

Medically necessary treatment that is otherwise covered under the health insurance contract cannot be denied solely because it is treatment for gender dysphoria.

Required conditions

The treatment is medically necessary.
The treatment is otherwise covered by the health insurance contract.
The treatment is not denied solely because it is for gender dysphoria.
New York DFS guidance prohibits denial on this sole basis.

Mental health utilization review

Utilization review determinations for mental health services must use age-appropriate, evidence-based, peer-reviewed clinical criteria consistent with WPATH SOC-8.

Mental health utilization review standard: Utilization review determinations for mental health services must be based on evidence-based, peer-reviewed clinical criteria appropriate to the patient's age and consistent with WPATH SOC-8.

This requirement is described under New York Insurance Law § 4902 and Public Health Law § 4902 provisions added in May 2024.

Product-dependent application of medical policy criteria

Medical policy criteria apply according to the member's product benefit and the applicable governmental coverage guidance.

Product-specific application

Commercial product: If a commercial product, including an Essential Plan or Child Health Plus product, covers the specific service, medical policy criteria apply to the benefit.
Medicaid product: If a Medicaid product covers the specific service and there are no New York State Medicaid guidelines (eMedNY) criteria, medical policy criteria apply to the benefit.
Medicare product: If a Medicare product, including a Medicare HMO-Dual Special Needs Program product, covers the specific service and there is no national or local Medicare coverage decision for the service, medical policy criteria apply to the benefit.
Medicare HMO-Dual Special Needs Program product without coverage:

Psychological techniques intended to alter a person's gender identity or expression to align with the sex assigned at birth—including conversion or reparative therapy—are excluded from the recommended treatment approach. These techniques are described as ineffective and harmful and should not be used to treat gender dysphoria.

Medical policy criteria are product dependent. If the member's product does not cover the specific service, these criteria do not apply. When the service is covered, apply the applicable product-specific requirements and any controlling governmental coverage guidance.

Coding Information

ModifiersModifier

KX	Requirements specified in the medical policy have been met; for use by physicians and non-physician practitioners
45	Ambiguous gender category; for use by institutional providers

ICD10 CodesICD-10

F64.0 - F64.9	Gender identity disorder (code range)
Z87.890	Personal history of sex reassignment

Provider Assessment and Practice Requirements

Documentation Required

Comprehensive Clinical Assessment Required

Diagnosis of gender dysphoria requires a comprehensive evaluation by qualified medical and behavioral health professionals. Assessment should be individualized, person-centered, and multidisciplinary, with appropriate screening, preventive services, and behavioral health care based on clinical need and the member’s circumstances.

Use the DSM-5-TR and ICD-10 criteria and diagnostic classifications as applicable.
Coordinate communication and care among relevant medical and behavioral health professionals.
Consider developmentally appropriate assessment for children, adolescents, and adults.
Assess and address psychological well-being, overall health, and individual care needs.

Denial Risk

Avoid Conversion or Reparative Therapy

Do not use psychotherapy or other psychological techniques intended to alter a person’s gender identity or gender expression toward the sex assigned at birth. Conversion and reparative therapy are ineffective, harmful, and inconsistent with appropriate gender-affirming care.

Policy Background

Gender dysphoria describes discomfort or distress associated with incongruence between a person's gender identity, sex assigned at birth, and/or primary or secondary sex characteristics. Gender-affirming care is individualized across the lifespan and may involve a multidisciplinary team, including behavioral health, primary care, endocrinology, reproductive and sexual health, voice and communication services, and surgery. Depending on individual clinical needs, care may include social transition, hormone therapy, psychotherapy, preventive care, and gender-affirming surgery.

Key Terms and Clinical Framework

Gender dysphoria

DefinitionExperienced discomfort or distress related to incongruence between a person’s gender identity, sex assigned at birth, and/or primary or secondary sex characteristics.

Clinical diagnosisBased on a comprehensive evaluation by qualified medical and behavioral health professionals.

Diagnostic referencesThe DSM-5-TR and ICD-10 provide criteria and diagnostic classifications.

Transgender and gender diverse (TGD)

MeaningA broad and comprehensive phrase describing people whose gender identities or expressions differ from the gender socially attributed to the sex assigned to them at birth.

ScopeIncludes members of many varied communities that exist globally.