CurrentIndependent HealthPolicy M20151112001

Gender Reassignment Treatment Policy

Defines medical necessity criteria, documentation, and coverage for hormone therapy and gender-affirming surgical procedures for members across Commercial, Self-Funded, MediSource, MediSource Connect, Essential Plan, and certain Medicare Advantage lines; includes exclusions and pre-authorization requirements for surgical care.

Policy Summary

PayerIndependent Health

PolicyGender Reassignment Treatment Policy

Policy CodePolicy M20151112001

Change TypeRevised (version history with latest 9/1/2024)

Effective DateJan 1, 2015

Next Review Date

Key ActionPre-authorization is required for surgical treatment; submit required mental health and surgeon documentation per policy.

SourceLink

POLICY UPDATE CHANGES

Policy shows multiple revisions with latest on 9/1/2024 noted as 'Revised'.

24Listed individual procedures/services referenced

5Explicit exclusions/examples of cosmetic procedures

3Key documentation letters/requirements

Coverage Summary

This policy defines medical necessity criteria and coverage for hormone therapy and gender‑affirming surgical procedures for members across multiple lines of business and follows New York State Department of Health clinical criteria. Hormone treatment is considered medically necessary when puberty has reached at least Tanner stage 2, a DSM‑5 diagnosis of gender dysphoria is documented by a licensed mental health professional, ongoing medical management is in place, and the member has adequate psychological and social support without psychiatric comorbidity that would interfere with care. For surgical treatment, members generally must be 18 years or older (exceptions for those under 18 may be allowed in exceptional circumstances with prior approval and demonstrated medical necessity), have the capacity to consent, and meet documentation requirements including mental health evaluation and, for genital surgery, evidence of at least 12 months of full‑time real‑life experience living in the preferred gender. Specific duration thresholds for hormone therapy are noted for surgical procedures (for genital surgery ≥ 12 months of appropriate hormone therapy unless contraindicated; for breast augmentation ≥ 24 months of hormone therapy when applicable).

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Key thresholds

Tanner stage for hormone therapy>= Tanner stage 2

Minimum age for surgery>= 18 years (exceptions for <18 with prior approval and demonstrated medical necessity)

Real-life experience duration>= 12 months living full-time in preferred gender prior to genital reassignment surgery

Hormone therapy duration for genital surgery>= 12 months unless medically contraindicated or unable to take hormones

Hormone therapy duration for breast augmentation>= 24 months (with negligible breast growth) unless contraindicated or unable to take hormones

Medical-Necessity Criteria

Hormone Treatment - Medical Necessity

Hormone treatment for gender dysphoria is considered medically necessary when ALL of the following are met:

ALL of the following

Tanner stage: Member has experienced puberty to at least Tanner stage 2 and pubertal changes have resulted in an increase in gender dysphoria.>= Tanner stage 2
Diagnosis of gender dysphoria has been made by a licensed mental health professional and fulfills DSM-5 criteria.
Pharmacy plan management: After an initial evaluation by a qualified medical professional, the pharmacy treatment plan is managed on an ongoing basis.
Support: Member has adequate psychological and social support during treatment.
Psychiatric comorbidity: Member does not suffer from psychiatric comorbidity that interferes with the diagnostic work-up or treatment.
Informed understanding: Member demonstrates knowledge and understanding of expected outcomes, medical and social risks and benefits of hormone treatment.
Adolescents: Post-pubertal adolescents (under 18) at Tanner stage 2 must meet the same criteria and documentation requirements as adults.
Monitoring and psychotherapy: Laboratory testing to monitor continuous hormone therapy and continued psychotherapy are considered medically necessary during hormone treatment.
Monitoring and psychotherapy considered medically necessary

Surgical Treatment - Medical Necessity

Gender reassignment surgery for gender dysphoria is considered medically necessary when ALL of the following are met:

ALL of the following

Diagnosis and motive: Diagnosis of gender dysphoria by a licensed mental health professional and fulfills DSM-5 TR criteria; disorder not due to another psychiatric disorder and member has demonstrated desire to live and be accepted in preferred gender.
Age: Member is 18 years of age or older (exceptions for <18 only in exceptional circumstances with prior approval noted elsewhere).>= 18 years
Note: Gender reassignment surgery is rarely appropriate for members under 18; requests for <18 considered only in exceptional circumstances on individual basis.
Capacity: Member has the capacity to make a fully informed decision and to consent to treatment.

New York State Specific Surgical Criteria (per NY State clinical criteria)

Per NY State, coverage may require additional documentation for certain members; ALL of the following must be met for coverage:

ALL of the following

Age (NYS): Individual is 18 years of age or older (coverage for <18 may be allowed if medical necessity demonstrated and prior approval received).>= 18 years (exceptions with prior approval)
Two letters requirement: Two letters from qualified NYS licensed health professionals who have independently assessed and are referring the individual for surgery; one letter must be from psychiatrist, psychologist, psychiatric nurse practitioner, or licensed social worker with established ongoing relationship; the other letter may be from a psychiatrist, psychologist, physician, psychiatric nurse practitioner or licensed clinical social worker (not required to be from different organization).Two independent letters

Procedures Covered Without Prior Medical Necessity Review

Coverage Without Prior Medical Necessity Review

Certain procedures are available without requiring a medical necessity review when prerequisites are met:

mastectomy

hysterectomy

salpingectomy

oophorectomy

vaginectomy

urethroplasty

metoidioplasty

phalloplasty

scrotoplasty

penectomy

orchiectomy

vaginoplasty

labiaplasty

clitoroplasty

testicular/penile prosthesis: placement of a testicular prosthesis and penile prosthesis

breast augmentation (provided: patient completed minimum of 24 months hormone therapy with negligible breast growth, or hormone therapy medically contraindicated, or patient unable to take hormones)>= 24 months hormone therapy unless contraindicated

electrolysis when required for vaginoplasty or phalloplasty

Not Covered / Exclusions

Not Covered / Exclusions (per NY State Department of Health)

Payment will not be made for the following services and procedures:

cryopreservation: Cryopreservation, storage, and thawing of reproductive tissue, and all related services and charges.

reversal genital/breast: Reversal of genital and/or breast surgery.

reversal secondary: Reversal of surgery to revise secondary sex characteristics.

reversal sterilization: Reversal of any procedure resulting in sterilization.

cosmetic exclusions: Cosmetic surgery, services, and procedures (examples provided), unless required for treatment of gender dysphoria and medical necessity prior approval received.

Examples of cosmetic exclusions: abdominoplasty, blepharoplasty, neck tightening, removal of redundant skin; breast augmentation (listed among exclusions but separately addressed as covered when criteria met); breast, brow, face, or forehead lifts; calf, cheek, chin, nose, or pectoral implants; collagen injections; drugs to promote hair growth or loss; electrolysis unless required for vaginoplasty; facial bone reconstruction/reduction/sculpturing including jaw shortening and rhinoplasty; hair transplantation; lip reduction; liposuction; thyroid chondroplasty; voice therapy, voice lessons, or voice modification surgery.

Provider Actions & Requirements

Prior Authorization

Pre-authorization required for surgical treatment

Pre-authorization is required for surgical treatment for Commercial, Self-Funded and Medicare Advantage members. Pre-authorization is not required for hormone treatment; hormone treatment criteria will be used for retroactive review (retroreview).

Documentation Required

Mental health documentation for surgical referral

Submit documentation from licensed mental health provider(s). For New York State surgical referrals, two letters from qualified NYS licensed health professionals who have independently assessed and are referring the individual are required; one letter must be from a psychiatrist, psychologist, psychiatric nurse practitioner, or licensed clinical social worker with an established and ongoing relationship. Together the letters must document persistent, well‑documented gender dysphoria; hormone therapy history (minimum 12 months for genital surgery unless medically contraindicated or unable to take hormones); 12 months living in a gender role congruent with identity and receipt of mental health counseling as deemed necessary; absence or control of contraindicating medical/mental health conditions; and capacity to make a fully informed decision and consent to treatment.

One letter must be from a psychiatrist, psychologist, psychiatric nurse practitioner, or licensed clinical social worker with an established and ongoing relationship (NYS requirement).
Two independent NYS-licensed evaluators required for NYS surgical coverage; letters must together establish the listed criteria.

Documentation Required

Surgeon physical exam documentation

The physician completing the pre‑operative physical examination must document in writing that there are no medical contraindications to surgical gender reassignment.

Documentation Required

Surgeon credentialing expectations

Surgeons performing gender-affirming procedures must have documented training and supervision in gender-affirming procedures, maintain an active practice in gender-affirming surgical procedures, demonstrate knowledge about gender diverse identities and expressions, engage in continuing education in gender-affirmation surgery, and track surgical outcomes.

Documented training and supervision in gender-affirming procedures
Maintenance of an active clinical practice in gender-affirming procedures
Tracking of surgical outcomes
Ongoing continuing education in gender-affirmation surgery

Denial Risk

Cosmetic exclusion denial risk

Services and procedures that are purely cosmetic and not medically necessary for treatment of gender dysphoria are excluded and payment will not be made. However, requests that appear cosmetic will still be reviewed for medical necessity and should not be automatically denied solely as cosmetic.

Denial Risk

Reversal and cryopreservation exclusions

Per New York State criteria, payment will not be made for cryopreservation, storage, and thawing of reproductive tissue or related services, nor for reversal of genital, breast, or sterilization procedures. These exclusions (cryopreservation/storage/thawing and reversals) will not be paid under the NYS criteria.

Step Therapy

Hormone therapy for MediSource/MediSource Connect/Essential Plan

For MediSource, MediSource Connect and Essential Plan members, hormone treatment requirements and any program-specific processes are specified in the Independent Health Pharmacy Policy Gender Dysphoria Treatment‑MediSource (policy M20150519031); refer to that policy for step requirements.

Coding

No procedure/cpt/hcpcs codes listed in policy textmixed

No codes listed

Background & Guideline References

The policy aligns with New York State DOH clinical criteria and references established professional guidance (notably WPATH Standards of Care and Endocrine Society/APA sources) to frame hormone and surgical treatments as components of multidisciplinary care involving medical, surgical, and behavioral health providers. Typical work‑up and monitoring include an extensive medical history, gynecologic/endocrine/urologic and psychiatric/psychological examinations, and laboratory testing to monitor continuous hormone therapy; surgeons are expected to have specialized training, maintain active practice, and track outcomes.

Evidence

Guideline referencesWPATH Standards of Care (v8), Endocrine Society clinical practice guideline, APA DSM-5

Definitions

Gender dysphoriaMarked difference between expressed/experienced gender and assigned sex at birth lasting at least six months causing clinically significant distress or impairment.

Real-life experienceAct of fully adopting a new or evolving gender role or presentation in everyday life; required 12 months for genital surgery prerequisites.

TransgenderUmbrella term for people whose gender identity and/or gender expression differs from their assigned sex at birth.

Medicare Determinations

NCD / LCD Name	Number	Type	Effective Date (if provided)
Gender Dysphoria and Gender Reassignment Surgery	140.9	NCD

Revision History

2024-09-01revisedLatest

Version control lists numerous prior review/revision dates; entry for 9/1/2024 noted as 'Revised'.

Policy Summary

PayerIndependent Health

PolicyGender Reassignment Treatment Policy

Policy CodePolicy M20151112001

Change TypeRevised (version history with latest 9/1/2024)

Effective DateJan 1, 2015

Next Review Date

Key ActionPre-authorization is required for surgical treatment; submit required mental health and surgeon documentation per policy.

SourceLink

On This Page

Real-life experience: Member has successfully lived full-time in the preferred gender for at least 12 months prior to genital reassignment surgery (real-life experience) without reverting to original gender.>= 12 months

Hormone therapy requirement: Hormone therapy may be considered but is not always required; hormone therapy is required for some surgeries unless medically contraindicated or not needed to achieve surgical result.Hormone therapy duration: >= 12 months for genital surgery unless contraindicated

Hormone therapy not required for mastectomy/reduction mastoplasty/breast augmentation; breast augmentation recommended after 12 months feminizing hormones when feasible

Mental health assessment: A mental health screening/assessment by a licensed mental health provider is required for referral to hormone and surgical treatments; continued psychotherapy recommended but not absolute unless recommended by mental health professional with specified goals and duration (usually minimum 3 months).

Control of comorbidities: If significant medical or mental health concerns are present, documentation that such conditions are reasonably well controlled prior to surgery.

Tobacco cessation: Counseling and assistance to become abstinent from tobacco/nicotine prior to gender-affirmation surgery is recommended.

Pre-op physical exam: Once criteria met and surgery approved, enrollee must undergo a complete physical examination by the surgeon performing the surgery.

Surgeon must indicate in writing there are no medical contraindications to surgical gender reassignment.

Surgeon qualifications: Surgeons performing gender-affirming procedures must have: training and documented supervision in gender-affirming procedures; maintenance of an active practice in gender-affirming procedures; knowledge about gender diverse identities and expressions; continuing education in gender-affirmation surgery; and tracking of surgical outcomes.

Surgeon qualifications and outcome tracking required

Letters must establish:

Letters together must establish: persistent and well-documented gender dysphoria; receipt of appropriate hormone therapy for minimum 12 months for genital surgery unless medically contraindicated or unable to take hormones; lived for 12 months in gender role congruent with identity and received mental health counseling as deemed necessary during that time; no other significant medical/mental health contraindications or if present they are reasonably well-controlled; and capacity to make fully informed decision and consent to treatment.

>= 12 months hormone therapy for genital surgery unless contraindicated; >= 12 months real-life experience

Physician completing physical exam must indicate no medical contraindications in writing