Prior Authorization Required

Prior authorization is required for gender-affirming surgical procedures and for hair removal when requested as a pre-operative intervention for planned genital surgery. Submit prior authorization requests with all required supporting clinical documentation to the Plan prior to scheduling procedures.

• Prior authorization required for listed CPT/HCPCS codes when submitted with gender-affirming diagnoses (see Codes section).
• Prior authorization for gender-affirming surgery must be obtained prior to requests for pre-operative genital hair removal.

Required Clinical Documentation and Letters

Provide comprehensive clinical documentation and letters demonstrating that ALL applicable clinical coverage criteria are met. Documentation must include a diagnosis of gender dysphoria/gender incongruence by one Qualified Health Care Professional and evidence addressing the Plan’s listed criteria for the specific surgical service requested.

• Letter(s) from Qualified Health Care Professional attesting to diagnosis of gender dysphoria/gender incongruence and readiness for medical/surgical treatment.
• Documentation that other possible causes for gender incongruence have been identified and excluded.
• Evidence that new self-identified gender has been present for >12 months and member has lived as affirmed gender if safe to do so, when applicable.
• Assessment and documentation that co-morbid medical/behavioral health conditions are reasonably controlled.
• Evidence of capacity to consent and informed decision-making.
• When required by the specific procedure, documentation of duration of continuous hormone therapy (typically ≥6 months; 12 months for adolescents <18 unless contraindicated).
• For hair removal for planned genital surgery: treating surgeon’s letter of medical necessity specifying size and location of area to be treated, timeline with expected number of treatments, and expected date of planned genital surgery.

Pre‑surgical Voice Therapy Required for Glottoplasty

For planned vocal cord surgery (glottoplasty) the Plan requires documentation of pre-surgical voice lessons and/or therapy provided by a licensed speech-language pathologist prior to approval, and that the procedure will be performed by an Ear, Nose and Throat (ENT) specialist.

• Documentation of pre-surgical voice lessons and/or therapy by a licensed speech-language pathologist.
• Evidence that an ENT specialist will perform the surgery.

Explicit Not Covered Services / Limitations

The Plan considers the services and procedures listed in Limitations as not medically necessary and not covered. Requests for services that fall into these categories may be denied. Review Limitations carefully before submitting authorization requests.

• Not covered examples include: body contouring procedures (e.g., abdominoplasty, panniculectomy, lipofilling), collagen injections, dermabrasion, chemical peels, hair removal except face/neck and required pre-operative genital hair removal per criteria, hair transplantation, implantations (calf, pectoral, gluteal), silicone injections, reimbursement for travel expenses, and phalloplasty for persons under 18.
• Reconstructive surgery to correct complications or functional impairment from prior gender-affirming procedures may be considered medically necessary; purely cosmetic or aging-related procedures are not covered.