Prior authorization required

Prior authorization is required for Gender Affirmation Surgery and Treatment; the member must meet the policy's eligibility criteria including having reached physical maturity and being 18 years of age or older, documented gender dysphoria for ≥12 months, under the care of a psychiatrist/psychologist for ≥12 months, living as the other gender for 12 months, and two attending physicians affirming medical necessity.

• Obtain prior authorization before scheduling gender-affirming procedures.
• Confirm member meets all listed eligibility criteria in the Procedure/Eligibility sections prior to submission.

Eligibility must meet Procedure-section qualifications

Coverage applies only when the member meets the specific qualifications listed in the Procedure section; if the member does not meet those qualifications, coverage does not apply.

• Verify each procedural-specific requirement (e.g., age, duration of dysphoria, behavioral health care, hormone therapy) in the Procedure section prior to authorization.

Minimum hormone therapy durations required for specified procedures

Certain procedures require documented completion of specified durations of hormone therapy prior to surgery unless hormones are not desired or are medically contraindicated.

• Breast augmentation: completion of six months of feminizing hormone therapy (12 months for adolescents <18) prior to surgery unless not desired/contraindicated.
• Gonadectomy and genital reconstructive surgery: six months of continuous hormone therapy as appropriate to gender goals (12 months for adolescents <18) unless not desired/contraindicated.
• For chest masculinization in members <18, completion of one year of testosterone is required unless not desired/contraindicated.

Step therapy not specified

The policy excerpt does not specify any step therapy protocols beyond the hormone therapy durations noted for certain procedures.

• No additional step therapy requirements are listed in this excerpt.

Required documentation to establish surgical eligibility

For surgical eligibility, obtain and include a signed letter from a qualified mental health professional assessing readiness, documentation of marked and sustained gender dysphoria, exclusion of other causes of gender incongruence, assessment of mental and physical health and capacity to consent, and documentation of required duration of hormone therapy when specified.

• Signed mental health professional letter assessing readiness for physical treatment.
• Documentation demonstrating marked and sustained gender dysphoria and exclusion of other causes.
• Assessment of mental/physical health risks and confirmation of capacity to consent.
• Document required hormone therapy duration where specified for the requested procedure.
• Assess and document procedure-specific risk factors (e.g., breast cancer screening consideration).

Additional documentation (as requested)

Provide any additional documentation required to meet policy, legal, or regulatory requirements as requested by the plan; the policy's Documentation section directs providers to supply such details.

• Respond to plan requests for supplemental documentation to satisfy legal/regulatory or policy-specific requirements.

Coverage requires meeting Procedure qualifications

If a member fails to meet the qualifications listed in the Procedure section, coverage does not apply and authorization should not be approved.

• Confirm all Procedure-section qualifications before submitting authorization; lack of required criteria (age, duration of dysphoria, clinician involvement, physician affirmations, etc.) is a basis for noncoverage.

Cosmetic/repeat procedures may be denied

Procedures that are cosmetic or repeat interventions may be considered not medically necessary and may be denied—for example, more than one breast augmentation (excluding medically necessary replacement of implants) and certain reversals are listed as not medically necessary.

• Do not expect coverage for multiple breast augmentations beyond replacement of implants unless implant replacement is medically necessary.
• Reversal of genital surgery or revision of secondary sex characteristics is listed among examples of excluded/cosmetic services, unless reversal meets the noted criteria for medical necessity.