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ModifiedPartners Insurance Company dba Jefferson Health PlansPolicy MN. 010.I

Gender-Affirming Surgery

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This policy governs medical necessity and coverage criteria for gender-affirming surgeries and related services for members across all Jefferson Health Plans lines of business, including Medicare Advantage, Individual and Family Plans, CHIP, and EverWell Medicaid.

Policy Summary

PayerPartners Insurance Company dba Jefferson Health Plans

PolicyGender-Affirming Surgery

Policy CodePolicy N/A

Change TypeModified

Effective DateN/A

Last ReviewDec 17, 2025

Next Review DateN/A

Key ActionObtain and document the surgeon’s pre-surgical evaluation within 6 months of the procedure request.

SourceLink

POLICY UPDATE CHANGES

The policy history reports revisions to terminology, the policy statement, and the coding sections during the annual review.

The policy history reports that coverage criteria were revised during a prior ad-hoc review.

CPT code 19318 for breast reduction was added to the coding table.

Nipple reconstruction was removed from the non-covered services section.

Gender-specific services for the transgender community were added to covered services, and more than one breast augmentation was added to non-covered services.

Facial feminization surgery, masculinization surgery, and fertility-preservation procedures were added to the non-covered section.

The product variation section was updated to include coverage for all lines of business.

6Criteria groups

12 monthsHormone therapy

18+Minimum age

18Potentially covered cosmetic procedures

4Non-covered categories

Medical Necessity and Coverage Criteria

General Surgical Medical Necessity

Covered when ALL of the following general surgical medical-necessity criteria are met:

ALL of the following

Referral from a qualified mental health professional is provided. In accordance with WPATH recommendations, the referral letter includes an assessment of gender identity and transgender/gender diverse (TGD) status; availability of support from family, friends, and peers, including in-person or online contact with transgender, transsexual, or gender-nonconforming individuals or groups; diagnosis of TGD based on DSM-5 requirements; history and development of TGD feelings; the impact of stigma attached to gender nonconformity on mental health; and psychological readiness for the requested surgeries.
Member demonstrates capacity to make a fully informed decision to consent to treatment.
Member has been living in the gender role congruent with the member's gender identity for a significant period of time.

Mastectomy

Policy Summary

PayerPartners Insurance Company dba Jefferson Health Plans

PolicyGender-Affirming Surgery

Policy CodePolicy N/A

Change TypeModified

Effective DateN/A

Last ReviewDec 17, 2025

Next Review DateN/A

Key ActionObtain and document the surgeon’s pre-surgical evaluation within 6 months of the procedure request.

SourceLink

On This Page

Mastectomy may be considered medically necessary for female-to-male members when ALL of the following criteria are met:

ALL of the following

Assessment by a qualified mental health professional results in a diagnosis of transgender/gender diverse (TGD) meeting DSM-5 criteria.
Member demonstrates capacity to make a fully informed decision to consent to treatment.
Member is 18 or older.
Members under 18 may be considered when they have completed 12 continuous months of physician-supervised hormone therapy appropriate to their gender goals, unless medically contraindicated, and 12 continuous months of full-time living in a gender role congruent with their gender identity. Legal guardian consent and letters from two qualified mental health practitioners who independently evaluated the member are also required.
Significant medical or mental health concerns, if present, are optimally managed and well controlled.
Referral for mastectomy from a qualified mental health professional has been provided.

Augmentation Mammaplasty

Augmentation mammaplasty with implantation of breast prostheses may be considered medically necessary for male-to-female members when ALL of the following criteria are met:

ALL of the following

Assessment by a qualified mental health professional results in a diagnosis of transgender/gender diverse (TGD) meeting DSM-5 criteria.
Member demonstrates capacity to make a fully informed decision to consent to treatment.
Member is 18 or older.
Members under 18 may be considered when they have completed 12 continuous months of physician-supervised hormone therapy appropriate to their gender goals, unless medically contraindicated, and 12 continuous months of full-time living in a gender role congruent with their gender identity. Legal guardian consent and letters from two qualified mental health practitioners who independently evaluated the member are also required.
Significant medical or mental health concerns, if present, are optimally managed and well controlled.
Referral for augmentation mammaplasty from a qualified mental health professional has been provided.

Hysterectomy, Salpingectomy, Oophorectomy, and Orchiectomy

Hysterectomy, salpingectomy, and/or oophorectomy may be considered medically necessary for female-to-male members, and orchiectomy may be considered medically necessary for male-to-female members, when ALL of the following criteria are met:

ALL of the following

Assessment by a qualified mental health professional results in a diagnosis of transgender/gender diverse (TGD) meeting DSM-5 criteria.
Member demonstrates capacity to make a fully informed decision and can consent to treatment.
Member is 18 or older.
Significant medical or mental health concerns, if present, are optimally managed and well controlled.
Member has completed 12 continuous months of physician-supervised hormone therapy appropriate to the member's gender goals, unless hormone therapy is medically contraindicated.
Hormone therapy may be concurrent with living in the gender role.
Referrals for hysterectomy, salpingectomy and/or oophorectomy or orchiectomy have been provided by two qualified mental health professionals who independently assessed the member.
One of the two referrals may be from the qualified mental health professional performing the initial assessment.

Genital Reconstructive Surgery

Genital reconstructive surgery may be considered medically necessary when ALL of the following criteria are met:

ALL of the following

Assessment by a qualified mental health professional results in a diagnosis of transgender/gender diverse (TGD) meeting DSM-5 criteria.
Member demonstrates capacity to make a fully informed decision to consent to treatment.
Member is 18 or older.
Significant medical or mental health concerns, if present, are optimally managed and well controlled.
Member has completed 12 continuous months of physician-supervised hormone therapy appropriate to the member's gender goals, unless hormone therapy is medically contraindicated.
Hormone therapy may be concurrent with living in the gender role.
Referrals for genital reconstructive surgery have been provided by two qualified mental health professionals who independently assessed the member.
One of the two referrals may be from the qualified mental health professional performing the initial assessment.

Procedures Usually Considered Cosmetic but Covered for Gender Affirmation

Procedures usually considered cosmetic may be covered for gender affirmation when ALL of the following criteria are met:

ALL of the following

Member is age 18 or older.
Assessment by a qualified mental health professional results in a diagnosis of transgender/gender diverse (TGD) meeting DSM-5 criteria.
Member demonstrates capacity to make a fully informed decision and can consent to treatment.
Significant medical or mental health concerns, if present, are optimally managed and well controlled.
Referral from a qualified mental health professional who independently assessed the member has been provided.
Member has completed 12 continuous months of physician-supervised hormone therapy appropriate to the member's gender goals, unless hormone therapy is medically contraindicated.
Hormone therapy may be concurrent with living in the gender role.
A pre-surgical evaluation by the surgeon was completed within 6 months of the procedure request and documents the nature of the planned surgical procedures, the expected timetable if surgery is staged, and a diagram of the specific area requiring preoperative hair removal, if applicable.

Benefit Application

This medical necessity policy applies only when ALL of the following benefit-application conditions are met:

ALL of the following

The requested service is an eligible benefit under the member's applicable benefit contract on the date the service was rendered.
Applicable benefit documents govern which services or items are eligible for coverage, subject to benefit limits or complete exclusions.
The member's applicable line of business and benefit documents are used to determine the benefits available; medical policies do not constitute a description of benefits.

The following procedures are usually considered cosmetic and are not covered for gender affirmation: body contouring procedures, including abdominoplasty, suction-assisted lipectomy, and lipofilling; Botox injections; calf implantation; chemical peels; collagen injections and dermal fillers, including Sculptra and Radiesse; dermabrasion; excision of redundant skin; gluteal augmentation, including silicone implants, fat transfer, and fat grafting; hair reconstruction, including hair removal/electrolysis, hair transplantation, and wigs, except during skin preparation for gender reconstructive surgical procedures; mastopexy; monsplasty; nontherapeutic tattooing; otoplasty; pectoral implantation; and skin resurfacing.

Gender-affirming surgery is not covered for members who are dissatisfied with their natal sex or prefer to be the opposite sex without clinically significant distress or impairment resulting in a diagnosis of transgender/gender diverse (TGD) meeting DSM-5 criteria.

Reversal of gender-affirming surgery is not covered.

More than one breast augmentation is not medically necessary. This limitation does not include medically necessary replacement of breast implants.

Procedures for preservation of fertility, including procurement, preservation, and storage of sperm, oocytes, or embryos, are not covered.

Services determined by the Plan to be investigational or experimental, cosmetic, or not medically necessary are excluded from coverage for all lines of business.

Coverage is subject to the applicable benefit contract. Applicable benefit documents determine whether a service or item is an eligible benefit and whether benefit limits or exclusions apply.

More than one breast augmentation is not medically necessary, except when the additional procedure is medically necessary replacement of breast implants.

Coding and Reference Requirements

CPT codes listed for referenceCPT

15820	Blepharoplasty, lower eyelid.
15821	Blepharoplasty, lower eyelid; with extensive herniated fat pad.
15822	Blepharoplasty, upper eyelid.
15823	Blepharoplasty, upper eyelid; with excessive skin weighting down lid.
15824	Rhytidectomy; forehead.
15825	Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap).
15826	Rhytidectomy; glabellar frown lines.
15828	Rhytidectomy; cheek, chin, and neck.
15829	Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap.
17380	Electrolysis epilation, each 30 minutes.

1–10 of 99

1/10

CPT hysterectomy, adnexal, and female genital system proceduresCPT

58543	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g
58544	Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58550	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less
58552	Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s)
58553	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g
58554	Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s)
58570	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
58571	Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58572	Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g
58573	Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

1–10 of 14

1/2

CPT reproductive medicine and fertility-preservation proceduresCPT

89258	Cryopreservation; embryo(s)
89335	Cryopreservation, reproductive tissue, testicular
89337	Cryopreservation, mature oocyte(s)
89342	Storage (per year); embryo(s)
89344	Storage (per year); reproductive tissue, testicular/ovarian
89346	Storage (per year); oocyte(s)
89352	Thawing of cryopreserved; embryo(s)
89354	Thawing of cryopreserved; reproductive tissue, testicular/ovarian
89398	Unlisted reproductive medicine laboratory procedure

CPT speech, language, voice, and communication treatmentCPT

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals

HCPCS reproductive preservation servicesHCPCS

S4030	Sperm procurement and cryopreservation services; initial visit
S4040	Monitoring and storage of cryopreserved embryos, per 30 days

ICD-10 diagnosis and history codesICD-10

F64	Gender identity disorders
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
Z87.890	Personal history of sex reassignment

Age requirement

Minimum age18 or older for specified gender-affirming procedures.

Procedures subject to the age requirementThe requirement applies to mastectomy, augmentation mammaplasty, hysterectomy, salpingectomy, oophorectomy, orchiectomy, genital reconstructive surgery, and procedures usually considered cosmetic but covered for gender affirmation.

Age exceptionsMembers under 18 may be considered for mastectomy or augmentation mammaplasty only when the additional requirements for under-18 chest surgery are met.

Physician-supervised hormone therapy

Required duration12 continuous months of physician-supervised hormone therapy appropriate to the member’s gender goals.

Medical-contraindication exceptionThe hormone-therapy requirement does not apply when hormone therapy is medically contraindicated.

Concurrent gender-role experienceFor hysterectomy, salpingectomy, oophorectomy, orchiectomy, genital reconstructive surgery, and covered procedures usually considered cosmetic, hormone therapy may be concurrent with living in the gender role.

Under-18 chest surgery exception

Hormone therapy12 continuous months of physician-supervised hormone therapy appropriate to the member’s gender goals, unless medically contraindicated.

Gender-role experience12 continuous months of full-time living in a gender role congruent with the member’s gender identity.

Additional requirementsLegal guardian consent and letters from two qualified mental health practitioners who have independently evaluated the member are required.

Surgeon pre-surgical evaluation

TimingThe surgeon must complete one pre-surgical evaluation within 6 months of the procedure request.

Planned procedure documentationThe evaluation must document the nature of the planned surgical procedure or procedures.

Additional documentationWhen surgery is staged, document the expected timetable; when applicable, include a diagram of the specific area requiring preoperative hair removal.

Voice modification surgery

Hormone-therapy prerequisiteVoice modification surgery is covered when needed after 12 months of hormonal therapy.

Voice-therapy prerequisiteVoice therapy is also required before voice modification surgery.

Examples of surgeryVoice modification surgery includes laryngoplasty and cricothyroid approximation.

Documentation, Review, and Denial Risks

Documentation Required

Pre-procedure Evaluation Required

Before a gender-affirming cosmetic procedure, the surgeon must complete and document one pre-surgical evaluation within 6 months of the procedure request. The evaluation must describe the planned procedure(s), provide the expected timetable for staged surgery when applicable, and include a diagram of the specific area requiring pre-operative hair removal, if applicable.

Evaluation timing: within 6 months of the procedure request.
Document the planned procedure(s), staged-surgery timetable when applicable, and applicable pre-operative hair-removal area diagram.

Documentation Required

Initial Mental-Health Referral Documentation

Obtain the required referral letter from a qualified mental health professional and ensure it addresses the member’s gender identity and TGD assessment, support system, DSM-5 diagnosis, history and development of TGD feelings, stigma-related mental-health impact, and psychological readiness for the requested surgery.

Document assessment of gender identity and transgender/gender diverse (TGD) status.
Address family, friend, and peer support; history and development of TGD feelings; stigma-related mental-health impact; and psychological readiness.
The diagnosis must meet DSM-5 requirements.

Documentation Required

Chest Surgery Documentation

For chest surgery, retain documentation demonstrating the applicable diagnosis, informed consent capacity, age requirement, management of significant medical or mental-health concerns, and referral. Additional requirements apply for members under age 18.

Mastectomy: qualified mental-health assessment with DSM-5 TGD diagnosis, informed consent capacity, age 18 or older, optimally managed concerns, and referral from a qualified mental-health professional.
Augmentation mammoplasty: qualified mental-health assessment with DSM-5 TGD diagnosis, informed consent capacity, age 18 or older, optimally managed concerns, and referral from a qualified mental-health professional.
For members under 18, document 12 continuous months of physician-supervised hormone therapy unless contraindicated, 12 continuous months of full-time living in the congruent gender role, legal-guardian consent, and letters from two independently evaluating qualified mental-health practitioners.

Documentation Required

Gonadal and Genital Surgery Documentation

For gonadal or genital surgery, document the required DSM-5 TGD diagnosis, informed consent capacity, age, management of significant concerns, hormone-therapy history when applicable, and referrals from the required qualified mental-health professionals.

Hysterectomy, salpingectomy, oophorectomy, or orchiectomy: document 18-or-older age, 12 continuous months of physician-supervised hormone therapy unless contraindicated, and referrals from two independently assessing qualified mental-health professionals; one referral may be from the initial assessor.
Genital reconstructive surgery: document 18-or-older age, 12 continuous months of physician-supervised hormone therapy unless contraindicated, and referrals from two independently assessing qualified mental-health professionals; one referral may be from the initial assessor.
For all applicable procedures, document DSM-5 TGD diagnosis, informed-consent capacity, and optimally managed significant medical or mental-health concerns.

Documentation Required

Gender-Affirming Cosmetic-Procedure Documentation

Procedures usually considered cosmetic may be covered for gender affirmation only when all listed clinical and procedural requirements are documented, including the surgeon’s pre-surgical evaluation within 6 months of the procedure request.

Member is age 18 or older and has a qualified mental-health assessment resulting in a DSM-5 TGD diagnosis.
Document informed-consent capacity, optimally managed significant medical or mental-health concerns, and referral from a qualified mental-health professional who independently assessed the member.
Document 12 continuous months of physician-supervised hormone therapy appropriate to the member’s gender goals, unless medically contraindicated; therapy may be concurrent with living in the gender role.
Surgeon evaluation must document the planned procedure(s), staged-surgery timetable when applicable, and a diagram of the area requiring pre-operative hair removal, if applicable.

Unsupported block type: documentation

Documentation Required

Maintain Medical-Necessity Records

Keep all documentation supporting medical necessity on file and present it to the Plan upon request. Medical-necessity determinations may also consider clinical data affecting the relative risks and benefits of the procedure, including postoperative recovery.

Retain the complete medical-necessity record.
Provide supporting documentation to the Plan upon request.
Apply the product-specific definition of medical necessity where state or federal regulatory requirements differ.

Denial Risk

Failure to Meet Medical-Necessity Criteria

Coverage may be denied when the applicable medical-necessity criteria are not met. Providers should verify and document every required diagnosis, consent, age, treatment, referral, and clinical-management element before submitting a request.

Required criteria include a qualified mental-health assessment and DSM-5 TGD diagnosis, capacity for fully informed consent, and living in a gender role congruent with the member’s gender identity for a significant period.
Procedure-specific criteria may include age 18 or older, optimally managed medical or mental-health concerns, hormone therapy, and one or two qualified mental-health referrals.
For procedures usually considered cosmetic, all applicable clinical and surgeon pre-surgical documentation requirements must be satisfied.

Denial Risk

Non-covered Services

The Plan does not cover listed cosmetic services or other excluded services, including reversals, more than one breast augmentation except medically necessary implant replacement, and fertility-preservation services.

Non-covered cosmetic services include body contouring, Botox, calf implantation, chemical peels, collagen injections and dermal fillers, dermabrasion, excision of redundant skin, gluteal augmentation, mastopexy, monsplasty, nontherapeutic tattooing, otoplasty, pectoral implantation, and skin resurfacing.
Hair reconstruction, including hair removal/electrolysis, hair transplantation, and wigs, is not covered except during skin preparation for gender reconstructive surgery.
Other exclusions: reversal of gender-affirming surgery; more than one breast augmentation, excluding medically necessary replacement of breast implants; and procurement, preservation, or storage of sperm, oocytes, or embryos.

Denial Risk

No Qualifying Clinical Diagnosis

Gender-affirming surgery is not covered when it is requested because the member is dissatisfied with their natal sex or prefers to be the opposite sex without clinically significant distress or impairment resulting in a DSM-5 TGD diagnosis.

A clinically significant distress or impairment-based TGD diagnosis is required.
Dissatisfaction or preference alone does not establish coverage.

Denial Risk

Benefit or Medical-necessity Exclusion

A request may be denied when the service is not an eligible benefit under the member’s applicable benefit contract or when the Plan determines that medical necessity is absent. Investigational, experimental, cosmetic, or not medically necessary services are excluded for all lines of business.

Confirm benefit eligibility on the date the service was rendered.
Apply applicable benefit limits and exclusions in the member’s benefit documents.
Medical policies assist in benefit administration and do not themselves describe coverage.

Note

PARP Criteria Exception Review

For Jefferson Health Plans EverWell and CHIP products, requests for services that do not meet PARP criteria are evaluated on a case-by-case basis.

Do not treat case-by-case review as an automatic approval or coverage guarantee.

Policy Background

The policy evaluates gender-affirming surgery and related services based on clinical documentation supporting a transgender/gender-diverse diagnosis, capacity for informed consent, psychological readiness or independent mental-health assessment, and applicable treatment history. Depending on the procedure, requirements may include age, hormone therapy, living in a gender role congruent with the member’s gender identity, management of significant medical or mental-health concerns, and qualified mental-health referrals.

Definitions

Transgender / gender diverse (TGD)

Diagnostic basisTransgender or gender diverse status is diagnosed based on DSM-5 requirements.

AssessmentThe diagnosis is assessed by a qualified mental health professional.

Referral documentationThe qualified mental health professional’s referral letter must include the assessment of gender identity and TGD status and the DSM-5-based TGD diagnosis.

Living in the gender role congruent with gender identity

MeaningLiving in the gender role congruent with gender identity means living in a gender role that is congruent with the member’s gender identity.

General requirementFor general surgical coverage, the member must have lived in the congruent gender role for a significant period of time.

Specified durationCertain procedures require 12 continuous months of full-time living in a gender role congruent with the member’s gender identity.

Gender-affirming surgery

DefinitionGender-affirming surgery is the surgical procedure or procedures by which a transgender person’s physical appearance and function of existing sexual characteristics are altered.

Treatment purposeThe alteration is intended to make the person’s physical appearance and function resemble those socially associated with the person’s identified gender.

Clinical contextGender-affirming surgery is part of treatment for transgender or gender diverse people.

Transgender / Gender Diverse (TGD)

Core conceptTGD describes distress or incongruence related to a mismatch between a person’s experienced gender and assigned gender.

Diagnostic emphasisDSM-5 shifts the clinical emphasis from cross-gender identification itself to possible distress arising from that mismatch or incongruence.

Adult manifestationsAdults may have a strong desire to replace physical sex characteristics with those of another gender, believe they have the emotions of their gender, desire treatment as another gender, or seek recognition as having an alternative gender identity.

Qualified Mental Health Professional

Treatment roleA qualified mental health professional diagnoses and treats adults presenting for care regarding gender identity or transgender or gender diverse status.

Education and licensureThe professional has a master’s degree or equivalent in a clinical behavioral science field from an appropriately accredited institution and is licensed by the relevant licensing board to practice in the Commonwealth of Pennsylvania.

Diagnostic competenceThe professional is competent to use the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders for diagnostic purposes.

Assessment capabilitiesThe professional can recognize and diagnose coexisting mental health concerns, distinguish them from TGD, and assess and treat TGD and gender-nonconforming identities and expressions.

Clinical trainingThe professional has documented supervised training and competence in psychotherapy or counseling.

Continuing educationThe professional maintains continuing education in the assessment and treatment of TGD, such as relevant meetings, workshops, seminars, supervision, or research participation.