Clarification of Prior Authorization Criteria for Transgender Services
Customize your policy alerts
Sign up for all integrated_home_care_services policy alerts
Know when integrated_home_care_services releases new policies or updates existing guidance.
Monitor payer policy activity
Clarifies prior authorization (PA) criteria and documentation requirements for gender‑affirming medical and surgical services for ForwardHealth (Wisconsin Medicaid/BadgerCare Plus) members, including additional criteria for minors. Affects providers submitting PA requests for these services.
Adds and clarifies PA criteria for transgender services in response to a court permanent injunction, referencing adherence to Section 1557 and WPATH guidance.
Coverage Criteria for Gender‑Affirming Services
General coverage criteria for transgender services
Covered when ALL of the following are met
Chest surgery criteria
Chest surgery may be approved when ALL of the following are met
Breast augmentation may be considered under the same criteria if distress regarding the body parts to be altered is documented by a mental health professional.
Genital surgery criteria
Genital surgery may be approved when ALL of the following are met
Examples of confirmation surgeries for transfeminine and transmasculine members are listed in the policy (e.g., orchiectomy, penectomy, labioplasty, vaginoplasty; hysterectomy, oophorectomy, vaginectomy, metoidioplasty, scrotoplasty).
Additional criteria for members under 18 years
For members <18 years, PA must include documentation that ALL of the following are met
Must be documented in the PA request.
Services listed under Wis. Admin. Code §§ DHS 107.03 and 107.06(5) remain noncovered and are not eligible for Prior Authorization through ForwardHealth. Examples explicitly cited in the administrative code and retained by policy include procedures for the enhancement of fertility, services that are experimental in nature, services that are cosmetic in nature, and hair transplants.
ForwardHealth considers a set of procedures to be cosmetic when they are performed primarily to improve appearance rather than to treat a medical condition; these procedures are not covered for gender‑affirming purposes unless they meet the separate restorative plastic surgery medical necessity criteria. Examples listed in the policy include blepharoplasty, facial implants, facial bone reconstruction or reduction, rhinoplasty, skin resurfacing, and trachea shave / thyroid cartilage reduction.
Procedures that are cosmetic, experimental, or specifically listed as noncovered under Wis. Admin. Code §§ DHS 107.03 and 107.06(5) are considered not medically necessary for coverage purposes and therefore remain noncovered unless otherwise qualifying under another medical‑necessity category (for example, restorative plastic surgery after trauma under the separate PA criteria).
Diagnosis and Coding Guidance
| F64.0 | Transsexualism |
| F64.1 | Dual role transvestism |
| F64.2 | Gender identity disorder of childhood |
| F64.8 | Other gender identity disorders |
| F64.9 | Gender identity disorder, unspecified |
| F66 | Other sexual disorders |
| Z41.8 | Encounter for other procedures for purposes other than remedying health state |
| Z41.9 | Encounter for procedure for purposes other than remedying health state, unspecified |
| Z87.890 | Personal history of sex reassignment |
Prior Authorization and Documentation Requirements
Prior authorization required; case‑by‑case review
Prior authorization is required for transgender services; PA requests are reviewed on a case‑by‑case basis and must include the clinical documentation and completed PA forms specified by ForwardHealth. Providers should submit the required materials with the initial PA request to allow clinical review against the coverage criteria.
Maintain and produce records on request
Follow the program's PA submission requirements and retain required records; produce documentation upon request by ForwardHealth per record retention rules.
Required documents to include with PA request
Submit a completed Prior Authorization Request Form (PA/RF, F-11018) and Prior Authorization/Physician Attachment (PA/PA, F-11016) with the PA request, plus clinical records from the treating mental health professional documenting diagnosis, current distress/functional impact, anticipated surgical impact, status/stability of coexisting mental health conditions, and clinical documentation substantiating the coverage criteria. Documentation of informed‑consent discussion must be retained in the medical record (not required with the PA).
- Completed PA/RF (F-11018) and PA/PA (F-11016)
- Clinical records from treating mental health professional showing transgender‑related diagnosis
- Documentation of current level of distress and impact on functioning over time
- Anticipated impact of requested surgery on distress and functioning
- Status and stability of coexisting mental health conditions
- Clinical documentation substantiating coverage criteria
- Informed consent discussion documentation retained in medical record (do not submit with PA)
Risk of denial or sanctions for missing documentation
Failure to produce or submit required documentation to ForwardHealth upon request may lead to denial or recoupment of payment and may result in sanctions, including termination from Wisconsin’s Medicaid program.
Policy Background and Context
ForwardHealth will review Prior Authorization requests for gender‑affirming care using the Wisconsin administrative code definition of medical necessity and clinical guidance consistent with WPATH best practices. Decisions are made on a case‑by‑case basis and require documentation that the member has clinically significant distress or impairment related to gender dysphoria, that dysphoria is not better explained by another mental health disorder, and that the member has the capacity to provide informed consent.
Definitions and Medical Necessity
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.