Prior authorization required

Prior authorization is required per the member's contract for gender-affirming surgical procedures; approval is contingent on meeting the diagnostic and procedure-specific criteria set forth in the policy (Procedure Number CMS24.08).

• Obtain prior authorization according to the member's SPD and the plan's authorization process before scheduling gender-affirming surgery.
• Authorization decisions depend on documented fulfillment of the policy’s diagnostic and surgical eligibility criteria.

Inpatient preauthorization required

All inpatient admissions require preauthorization; failure to obtain required preauthorization for an inpatient admission may result in denial or further review per plan rules.

• Verify inpatient authorization requirements with the member's specific SPD before admission.
• Obtain and document preauthorization prior to inpatient procedures when the service will be an inpatient stay.

Policy identification (CMS24.08); no explicit PA steps in excerpt

The policy is identified as Procedure Number CMS24.08 with approval and effective dates listed; the excerpt does not describe step-by-step prior authorization submission procedures.

• Policy identifier: CMS24.08. Approval Date: 01/20/2026. Effective Date: 04/01/2026.
• Follow plan-specific prior authorization submission processes (not detailed in this excerpt).

Prior authorization implied for listed CPT codes

The policy enumerates select CPT procedure codes for gender-affirming surgeries and related procedures; prior authorization is implied for these listed procedures and should be obtained per plan requirements.

• Examples of listed CPT codes appear in the coding sections (see policy code tables for full lists).
• Obtain prior authorization when billing any of the enumerated CPT codes for gender-affirming services under the member's plan.

Policy approval and follow plan PA processes

This policy was approved by MPAC and becomes effective 04/01/2026; providers should follow the policy and the member’s plan documents for prior authorization and approval processes.

• Approval: MPAC (01/20/2026); Effective: 04/01/2026.
• Follow the plan’s authorization processes and SPD language when submitting requests for approval.

Pharmacy and hormone coverage — consult formularies

Consult plan pharmacy formularies and the member's SPD for coverage and any plan-specific requirements for puberty suppression and gender-affirming hormone therapy.

• Pharmacy/formulary coverage and any utilization management requirements (e.g., prior authorization) are determined by the plan formulary referenced in Section III.

Document collaborative multidisciplinary agreement before surgery

Before referral for genital gender-affirming surgery, obtain collaborative documentation showing agreement between the mental health professional and the clinician responsible for endocrine therapy that surgery is medically necessary.

• WPATH and Endocrine Society guidance recommend that the mental health professional and the clinician responsible for endocrine treatment agree that genital surgery is medically necessary prior to referral.
• Document multidisciplinary collaboration (mental health, endocrine, surgical) especially for adolescent referrals.

No step therapy rules in excerpt

No step therapy rules for gender-affirming treatments or medications are detailed in the provided excerpt.

• The policy does not specify step therapy requirements in the shown sections; review the full policy or plan documents for any plan-specific pharmacy management rules.

Coding and documentation note — excerpt lists codes but not templates

The document lists CPT/HCPCS codes and policy header information but this excerpt does not include specific additional documentation templates or forms beyond the letter of medical necessity requirements.

• Coding disclaimer: inclusion of codes is informational and does not itself indicate coverage; benefits are determined by the member's SPD.
• Adherence may be monitored via post-payment review or audits.

Required documentation: referral / letter of medical necessity

A referral/letter of medical necessity from a qualified licensed healthcare professional is required and must document that the member meets diagnostic criteria, that gender dysphoria/incongruence is marked and sustained, capacity for informed consent, understanding of reproductive effects and fertility options, exclusion of other causes, and assessment of coexisting mental/physical conditions.

• For adults, letters must also document duration and, for gonadectomy, six months of hormone therapy unless hormone therapy is not desired or is medically contraindicated.
• For adolescents, a comprehensive biopsychosocial assessment by qualified mental health and medical professionals is required and the letter must address capacity, maturity, and fertility counseling.

Multidisciplinary documentation recommended

Clinical determinations should be made by qualified professionals and multidisciplinary documentation (mental health, endocrine, surgical team) is recommended, particularly for adolescents and for genital surgeries.

• WPATH SOC-8 and Endocrine Society guidelines are referenced as the clinical guidance supporting multidisciplinary assessment.
• In adolescents, an expert multidisciplinary team is endorsed; in its absence, recommended collaboration between pediatric endocrinologist, mental health professional, and other providers.

Excerpt lacks further documentation detail

This excerpt primarily lists procedure codes and policy header information and does not contain additional documentation requirements beyond those for letters of medical necessity and multidisciplinary assessment.

• Refer to the full policy for any additional forms, checklists, or required supporting clinical records.

Include ICD-10 gender identity codes with requests/claims

Use the listed ICD-10 diagnosis codes related to gender identity (F64.0, F64.2, F64.8, F64.9) and Z87.890 (personal history of sex reassignment) as supporting diagnosis codes when submitting authorization requests and claims.

• These ICD-10 codes are provided for informational purposes and are expected to accompany claims and documentation for gender-affirming procedures.

Cite supporting clinical references in documentation

References and clinical literature (e.g., WPATH SOC-8, Endocrine Society guideline, UpToDate chapters, systematic reviews) are cited in the policy and should be used to support clinical rationale in authorization documentation.

• Cite WPATH SOC-8 and Endocrine Society guidance when clinical assessments reference standard-of-care recommendations.
• Include relevant literature citations in complex or case-by-case authorization requests as appropriate.

Pharmacy/medication coverage — check plan formulary

For puberty suppression and gender-affirming hormone coverage, consult the plan’s pharmacy formulary and SPD for any medication authorization or utilization management requirements.

• Pharmacy coverage details (including prior authorization) are determined by Employer Health Programs formulary guidance referenced in Section III.

Document collaborative care before surgical referral

Prior to surgical referral, ensure documented collaboration and agreement between mental health and endocrine clinicians that surgery is appropriate and that risks, timing, and hormone management are addressed.

• Document that the clinician responsible for endocrine treatment and the mental health professional both concur surgery is medically necessary for genital procedures.
• For adolescents, ensure documentation of multidisciplinary team input or documented collaboration per WPATH SOC-8.

No step therapy rules provided

The policy excerpt contains no step therapy requirements or sequencing rules for gender-affirming medications or interventions.

• If step therapy or other pharmacy management rules are suspected, verify in the full policy or the member’s SPD/formulary.

Coding mismatch risk — match billed codes to policy lists

Ensure procedural coding matches the listed CPT/HCPCS codes in the policy; miscoding of procedures such as hysterectomy, vaginectomy, oophorectomy, or urethroplasty may lead to claim denials or processing issues.

• Use the policy’s coding tables when assigning CPT/HCPCS codes to gender-affirming surgical claims.
• Be aware the coding disclaimer states inclusion of codes is informational and benefit coverage is determined by the member’s SPD.

No changes to policy criteria

There are no changes to the policy criteria in the current revision; authorization criteria remain as previously stated.

• Revision history (01/20/2026) notes: 'No changes to policy criteria.'