Gender-Affirming Care Prior Authorization and Coverage Criteria
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Defines Maryland Physicians Care coverage, required documentation, and prior authorization requirements for gender-affirming medical treatments, fertility preservation, and surgeries for members when criteria are met.
No material clinical or coverage changes in this revision.
Coverage Criteria for Gender-Affirming Care
Gender affirming medical treatments (incl. puberty suppression, cross-sex hormones, voice therapy, fertility preservation)
Covered when ALL of the following are met:
Adolescents must have reached Tanner stage 2 for pubertal suppression.
Initial fertility preservation
Covered when ALL of the following are met:
Initial authorization period is 60 days when criteria are met.
Gender affirming surgeries
Covered when ALL of the following are met:
Exceptions allowed when hormone therapy is not clinically indicated, contraindicated, or inconsistent with the patient's goals.
Revision and reversal procedures
Covered when ALL of the following are met:
Revisions for complications of the original procedure (e.g., infection or functional impairment) may be considered medically necessary.
Non-covered items and limitations are specified. Non‑FDA approved medications, over‑the‑counter (OTC) products, and compounded drugs that do not have an existing billing code are not covered. Donor reproductive materials including donor sperm and donor oocytes are expressly excluded. Routine fertility procedures such as in vitro fertilization (IVF), intrauterine insemination (IUI), and services related to long‑term storage or thawing of sperm, oocytes, or testicular tissue (including sperm/oocyte banking, storage, and thawing) are not covered. Prepubertal testicular tissue cryopreservation is considered investigational and excluded from coverage. For fertility preservation services that are covered (for example, consultation, oocyte retrieval, cryopreservation, and certain gonadal suppression therapies), refer to the specific coverage criteria and prior authorization requirements.
Revision or reversal procedures are not routinely covered unless they meet medical necessity documentation requirements. Coverage may be considered when the treating healthcare professional documents that the proposed revision or reversal is medically necessary to address the member's gender incongruence, and the procedure is specific to feminization, masculinization, or non‑binary transition rather than being performed for unrelated cosmetic reasons or to reverse normal aging. Revisions that address complications of the original procedure (for example, infection or functional impairment) may be considered medically necessary and covered when the clinical documentation supports that determination.
Coding, Staging, and Authorization Durations
| No codes listed |
Provider Actions, Documentation, and Prior Authorization
Prior authorization required for all gender‑affirming benefits; fertility preservation PA authorized 60 days
Prior authorization (PA) is required for all gender-affirming care covered benefits. For initial fertility preservation requests, PA will be authorized for 60 days if the criteria are met; providers should refer to the MDH Medicaid FFS fee schedule for current codes when submitting requests.
- All gender affirming care covered benefits require prior authorization.
- Initial fertility preservation authorizations are valid for 60 days when criteria are met.
- Use the MDH Medicaid FFS fee schedule for current billing codes.
Monitoring labs required for hormone therapy; some tests may need PA
Laboratory testing is part of monitoring for hormone therapy and may be required by the plan; some monitoring tests may also require prior authorization.
- Monitoring labs are required for hormonal therapy management.
- Some laboratory tests used for monitoring may need separate prior authorization.
Required documentation: informed consent, medical necessity, assessment letters, provider attestations, certification form
All requests must include informed consent (parent/guardian consent for members under 18 per MPC policy 8000.33), documentation of medical necessity including required letters of assessment (SHP for adults; SHP or MHP from a multidisciplinary team for adolescents), provider attestations of marked and sustained gender incongruence and capacity to consent, and the Gender Affirming Care - Medical Necessity Healthcare Provider Certification Form.
- Informed consent documented; parental/guardian consent for minors per policy 8000.33.
- Adults: at least one assessment letter from an SHP with competencies in transgender care.
- Adolescents: at least one assessment letter from an SHP or MHP who is part of a multidisciplinary team.
- Provider attestation of marked and sustained gender incongruence and assessment of capacity to consent.
- Include the Gender Affirming Care - Medical Necessity Healthcare Provider Certification Form with the request.
Fertility preservation documentation: consent, treatment plan, iatrogenic infertility, RE specialist
Fertility preservation requests must include signed consent (parent/guardian consent for minors per MPC policy 8000.33), a copy of the proposed treatment plan, documentation of iatrogenic infertility when applicable, and the requesting/treating provider must be a reproductive endocrinologist.
- Signed consent required; parental/guardian consent for minors per policy 8000.33.
- Submit a copy of the treatment plan for the proposed fertility preservation services.
- Provide documentation of iatrogenic infertility when applicable (e.g., impairment from surgery, radiation, chemotherapy).
- Requesting/treating provider must be a Reproductive Endocrinologist.
Denial risk if prior authorization not obtained
Requests for gender-affirming services submitted without prior authorization may be denied because MPC requires prior authorization for all gender affirming care covered benefits.
- Do not submit claims or schedule procedures assuming retroactive authorization; obtain PA before providing services.
- Failure to obtain PA may result in denial of the request.
Background
Gender incongruence (also referred to as gender dysphoria) is managed across a spectrum of interventions ranging from reversible medical treatments to surgical procedures. Interventions include puberty suppression for adolescents, cross‑sex or gender‑affirming hormone therapy, non‑surgical supports such as voice therapy, fertility preservation options (for example, oocyte or sperm cryopreservation), and a variety of gender‑affirming surgeries addressing chest, genital, facial, trunk, and other body areas. Clinical assessment prior to treatment must establish marked and sustained gender incongruence, evaluate capacity for informed consent (or assent with parental/guardian consent for minors per MPC policy 8000.33), and assess comorbid mental and somatic health conditions with discussion of risks and benefits. For adolescents, pubertal stage and emotional/cognitive maturity are required considerations before initiating puberty suppression or other interventions.
Definitions
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