ModifiedPremera BluecrossPolicy N/A

Gender Transition/Affirmation Surgery and Related Services

Defines coverage criteria, site-of-service rules, documentation requirements, and permissible procedures for gender transition/affirmation surgical and related services under Premera plans; applies to providers and members seeking coverage determinations. Individual member contract language may further restrict or exclude services.

Policy Summary

PayerPremera Bluecross

PolicyGender Transition/Affirmation Surgery and Related Services

Policy CodePolicy N/A

Change TypeInterim clarifications and code additions

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionVerify benefits and obtain required mental health recommendation documentation (one dated evaluation within 12 months) and prior authorization when applicable.

SourceLink

POLICY UPDATE CHANGES

For hair removal, either current or past confirmation of the diagnosis of Gender Dysphoria, and either current or past verification or demonstration that all diagnostic criteria are met, are acceptable.

Added CPT codes 21615, 21811, 21899 and HCPCS codes L8600 & L8699, effective October 1, 2025.

Removed requirement that prior surgery must have been covered at the time it was performed; replaced with coverage availability under the individual's current health benefit plan.

Revisions, correction of incomplete or incorrectly done surgery, and correction or repair of complications are considered not medically necessary when the original surgery was determined to be not medically necessary, except when an emergency or potential emergency exists.

18+min age for most covered surgeries

12 moauthorization validity

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Coverage Criteria and Clinical Requirements

Medically necessary coverage criteria

Covered procedures when ALL required documentation and conditions are met

General coverage prerequisites: Diagnosis of Gender Dysphoria confirmed by a licensed mental health professional AND individual is aged 18 years or older AND one recommendation letter or medical record documentation from a licensed mental health professional based on a pre-surgery evaluation or psychotherapy or mental health treatment within the last 12 months (for prospective requests) or an evaluation/psychotherapy/mental health treatment in the 12 months immediately preceding the surgery for retrospective requests.12 months

Letters/medical record documentation must specify the date(s) of evaluation or treatment within the previous 12 months and meet required content (see Documentation Requirements).

Evidence of persistence or preparation: At least one of the following: documentation of persistent gender incongruence/gender dysphoria over time; evidence of hormone therapy appropriate to the desired gender identity for the immediately preceding 12 months; or evidence of living full-time in the gender role appropriate for the desired gender identity for the immediately preceding 12 months.12 months

These items are alternative demonstrations that the individual's decision is well thought out as described in Documentation Requirements.

Context and intent: No documentation or indication that the surgery/procedure is being done for reasons other than feminization, masculinization, or non-binary transition (e.g., solely cosmetic reasons or to reverse normal aging); refer to member contract language for covered procedures.

Specific procedures that may be covered depend on the member's plan; verify member contract.

Revisions, complications, and reversal

Coverage for complications, revisions, and reversals

Correction/repair of complications: Surgery to correct or repair complications of previously authorized gender transition/affirmation surgery is medically necessary when documentation shows specific complications that are causing pain, functional impairment, significant deformity, or are likely to cause functional impairment or a serious medical/surgical condition.

If the original surgery was done when the individual was not covered by a Company plan, coverage is available only if coverage for the original surgery is available under the individual's current health benefit plan or if the complication is causing or likely to cause a medical/surgical emergency.

Revision of appearance: Revision (including scar revision) is medically necessary when documentation from an evaluating clinician verifies or demonstrates that the proposed revision is expected to improve feminine/masculine/non-binary appearance and is expected to decrease the individual's gender dysphoria, or when previous surgery resulted in a significant deformity verified on physical examination.

Revision for dissatisfaction alone (absent pain or functional impairment) is subject to member contract terms and plan coverage rules.

Reversal and redo:

Hair removal and tattooing

Hair removal and medical tattooing

Hair removal for genital surgery: Covered when either genital surgery was authorized under a Company plan within the last 12 months OR current or past confirmation of Gender Dysphoria and current or past verification or demonstration that all diagnostic criteria are met; individual is aged 18 years or older; documentation specifies the body area(s) to be treated and that hair removal will be from existing genital sites or donor tissue to be used for genitals; hair removal is performed in a clinic/office setting outside a hospital by appropriately licensed/certified providers.12 months

Preauthorization required when genital surgery has been authorized within the last 12 months; a mental health recommendation is not required for hair removal.

Facial/body/extremity hair removal (non-genital): Covered when current or past confirmation of Gender Dysphoria and verification or demonstration that diagnostic criteria are met; individual is aged 18 years or older; performed in a clinic/office setting outside a hospital by licensed/certified providers; hair removal must be for feminization or non-binary transition (masculinization not covered unless related to genital surgery).

If location not specified, hair removal is presumed to be facial/body/extremity and may require up to a year of treatment at typical frequencies.

Fertility preservation

Fertility preservation prior to surgery: Procurement, cryopreservation, and storage of sperm, oocytes, or embryos performed prior to gender transition/affirmation surgery are considered medically necessary, except for plans that do not include assisted reproduction benefits; verify member contract.

Verify member contract for assisted reproduction benefit exclusions.

Mental health recommendation and documentation criteria

Covered when ALL of the following are met for surgeries requiring mental health recommendation:

Minimum mental health documentation: One recommendation letter or medical record documentation from a licensed mental health professional based on a pre-surgery evaluation or psychotherapy or mental health treatment within the last 12 months (prospective) or an evaluation/psychotherapy/mental health treatment in the 12 months immediately preceding surgery (retrospective).12 months

The letter/record must specify the date(s) of the most recent evaluation/treatment within the previous 12 months; dating a letter alone is insufficient.

Required content of recommendation: Recommendation must confirm the diagnosis of Gender Dysphoria and verify that the decision to proceed is well thought out (or show 12 months of appropriate hormone therapy or 12 months living in the desired gender role); verify the decision is not due to another untreated mental disorder; document that any comorbid psychiatric disorders are reasonably well-controlled and not contraindications to surgery; verify capacity to consent; if disorders impair reality testing, document that reality testing is intact and disorders are stabilized.

See Documentation Requirements for full list of required elements.

Procedure-specific coverage clarifications

Procedure-specific stance and components (examples):

Mastectomy/breast reduction: A trial of hormone therapy is not required. Nipple/areola reconstruction (including free nipple grafting) and chest contouring (including liposuction) are medically necessary components of covered mastectomy when performed at the same time; when delayed they may be considered cosmetic per plan terms. Nerve repair during mastectomy is medically necessary when indicated to prevent post-mastectomy pain syndrome. Mastectomy after prior breast reduction is considered a new procedure and requires meeting all criteria.

Concurrent components are covered; delayed procedures may be subject to plan exclusion.

Augmentation mammoplasty: A trial of hormone therapy is not required. Augmentation may be performed with implants, autologous fat transfer, or both. Liposuction and mastopexy are medically necessary when performed concurrently; when delayed they may be considered cosmetic. Additional augmentation can be considered medically necessary if criteria are met.

Evaluate each request per plan criteria for additional augmentation or revision.

Genital surgery: A trial of hormone therapy is not required. Penile prostheses for gender transition/affirmation are covered unless excluded by the member's plan; preoperative hair removal is necessary when hair will be from existing genital sites or donor tissue as documented.

Preoperative and ancillary services

Services related to surgery:

Hair removal services: Hair removal (laser or electrolysis) prior to genital surgery is covered when documentation demonstrates removal from existing genital sites or donor tissue to be used for genitals; a mental health recommendation is not required for hair removal. Local anesthesia or nerve block for covered hair removal is medically necessary. Providers must be appropriately licensed/certified and procedures performed in licensed facilities or approved settings.

Extent of hair removal may require up to one year of treatment at typical frequencies.

Preoperative imaging and ENT work-up: CT imaging is medically necessary for pre-surgery planning when facial feminization or masculinization surgery is determined to be medically necessary. An otolaryngology work-up (including laryngoscopy with stroboscopy and speech therapy consultation) is medically necessary prior to covered voice modification surgery to assess candidacy and set realistic expectations.

Order studies only when clinically indicated per surgical plan.

Postoperative corrective and revision procedures

Correction, revision, reversal, and complications:

Complication repair coverage: Correction or repair of complications of previously authorized gender transition/affirmation surgery is covered when documentation shows specific complications causing pain, functional impairment, or significant deformity; coverage is not provided when the original surgery was determined to be not medically necessary except if the complication is causing or likely to cause a medical/surgical emergency.

Self-funded ERISA group plan terms may alter coverage; verify member contract.

Revision of appearance after prior surgery: Revision (including scar revision) may be covered when expected to improve appearance and decrease gender dysphoria or when prior surgery resulted in a verified significant deformity; coverage depends on plan terms and member contract language.

Dissatisfaction alone without pain/functional impairment may be excluded depending on plan.

Reversal and redo due to complications: Reversal or redo is covered when documentation demonstrates that correction or repair of complications requires revision or undoing of the original genital or breast/chest procedure, or when serious medical indications necessitate reversal; coverage may depend on whether coverage for the original surgery is available under the current plan.

Coverage criteria for complication repair and revision/reversal

Covered when ALL of the following documentation and clinical context are present:

Complication documentation: Document the specific complications that are causing pain, functional impairment, or significant deformity; include clinical findings and rationale that surgery is required to correct/repair the complication.

Required to support coverage for corrective surgery of previously authorized procedures.

Revision/Reversal justification: Document that correction or repair of complications requires revision, undoing, or redoing of the original genital or breast/chest procedure; provide evidence that expected benefit outweighs risk.

Supports medical necessity determinations for revision or reversal procedures.

Multidisciplinary evaluation: Care is provided as part of a long-term multidisciplinary diagnostic process including extensive case history, relevant gynecologic/endocrinologic/urologic examinations, and clinical psychiatric/psychological evaluation by qualified mental health professionals.

Demonstrates readiness and appropriate context for irreversible surgical interventions.

Medical necessity for gender reassignment surgery

Covered when ALL of the following are met

Multidisciplinary diagnosis and readiness: Accurate diagnosis of Gender Dysphoria established through a long-term multidisciplinary diagnostic process that includes an extensive case history, relevant physical examinations (gynecologic, endocrinologic, urologic as applicable), and a clinical psychiatric/psychological examination by a qualified mental health professional; demonstration of readiness for irreversible surgical interventions and multidisciplinary recommendations as applicable.

Mental health professionals play a strong role in diagnosis, counseling, and assessing eligibility and readiness for surgery.

Preoperative hormone therapy

Policy statements regarding pre-surgery hormone therapy and augmentation mammoplasty

Hormone therapy prior to augmentation: Pre-surgery hormone therapy is not required for augmentation mammoplasty; evidence does not demonstrate clinically significant patient-centered benefit from requiring hormone therapy prior to breast augmentation.

Requirement removed based on 2023 evidence review.

Investigational/experimental procedures

Investigational procedures

Investigational surgeries: Uterine transplantation and penile transplantation (distinct from penile prostheses) for gender transition/affirmation are considered investigational due to insufficient evidence and feasibility concerns.

Penile transplantation reports are few and not for gender transition; uterine transplantation faces anatomical and rejection challenges.

General coverage criteria highlights

Covered when ALL of the following are met (select highlights from this window of the policy):

Mental health documentation specifics: Mental health recommendation/support must document history of gender dysphoria/gender incongruence, persistence over time, and dates of recent evaluation or treatment within the previous 12 months; a general statement that WPATH criteria are met is not sufficient.dates within previous 12 months

Letters must specify date(s) of most recent evaluation/treatment within prior 12 months.

Authorization validity: Authorizations for surgery and procedures are valid for 12 months from the date of authorization; a new authorization is required if the authorized surgery/procedure is not completed within 12 months.12 months

If surgery is not completed within 12 months, updated documentation (including possible MH recertification per timing rules) may be required.

Genital surgery mental health recommendations:

Medical necessity criteria and exceptions

Policy includes criteria and notes about medical necessity and exceptions

Revisions/corrections/complications policy: Revisions, correction of incomplete or incorrectly done surgery, and correction or repair of complications are considered not medically necessary when the original surgery was determined to be not medically necessary, except when an emergency or potential emergency exists or when a complication is causing or likely to cause functional impairment or a serious medical/surgical condition; coverage for original surgery under the individual's current plan affects eligibility.

Some self-funded ERISA group plans may have different terms; verify member contract.

Hair removal diagnostic timing: For hair removal, either current or past confirmation of the diagnosis of Gender Dysphoria, and either current or past verification or demonstration that all diagnostic criteria are met, are acceptable.

This clarification approved 02/23/2026 allows prior confirmation or verification to be used.

Mental health recommendation reuse timing: A new mental health recommendation is not required for any authorized surgery or procedure requested within two years of a prior authorization that included a qualifying mental health recommendation; documentation must still show dates of evaluation/treatment within the previous 12 months or frequency demonstrating evaluation within that period when required.

Uterine transplantation and penile transplantation (distinct from penile prostheses) are considered investigational for gender transition/affirmation due to insufficient evidence and feasibility concerns; uterine transplant studies are limited and present anatomical and rejection challenges, and penile transplants have been reported only rarely and not for gender transition to date. Reversal of a gender transition/affirmation surgery is not medically necessary except when there is a serious medical barrier to completing transition or a serious medical condition necessitating reversal; coverage for reversal when the original procedure was done while the member was not on the plan depends on whether coverage for the original surgery is available under the member’s current health benefit plan.

Procedures performed after the initial operation (examples include nipple/areola reconstruction or free nipple grafting, chest contouring or chest liposuction, liposuction for fat harvest, mastopexy, and additional breast augmentation) are considered medically necessary when performed as components at the same time as the covered primary procedure. When these same procedures are performed at a later date they are typically treated as cosmetic or feminization/masculinization procedures and subject to the member contract’s coverage or exclusion terms; additional breast augmentation after an initial augmentation may be considered medically necessary only if all applicable criteria are met.

Services that are primarily cosmetic — intended to preserve or improve appearance rather than to improve or restore bodily function — are excluded from coverage under this policy. Examples include procedures done solely to change or enhance appearance without restoring function; when a service is cosmetic, coverage depends on the member contract and plan-specific exclusions.

Coverage varies by plan: some plans exclude some or all gender transition/affirmation services. Penile prostheses/implants used to treat sexual dysfunction may be excluded by some plans for that indication, but an exclusion for penile prostheses for sexual dysfunction does not automatically apply to penile prostheses when used as part of gender transition/affirmation. Always verify member contract language or contact customer service to confirm plan-specific coverage.

Correction, revision, or reversal of a prior procedure is not medically necessary when the original surgery was determined to be not medically necessary, except when a complication is causing or is likely to cause a medical or surgical emergency. For corrections of incomplete or incorrectly done surgery, reimbursement and coverage may depend on whether coverage for the original surgery is available under the member’s current health benefit plan.

Reversal procedures are considered not medically necessary unless documentation shows a serious medical barrier to completing transition or a serious medical condition requiring reversal. Corrections or revisions may be approved when documentation demonstrates that the original procedure was incomplete or incorrectly done and that correcting it is medically indicated; if the original procedure was not medically necessary, correction/revision is generally not covered except for emergency complications or when current plan coverage of the original surgery is available.

When the original surgery was determined to be not medically necessary, requests for correction, revision, or repair of complications are treated as not medically necessary, with the exception of situations where a complication is causing or is likely to cause a medical or surgical emergency. If the prior procedure was performed while the member was not on the plan, coverage for correction or reversal depends on whether the original surgery is covered under the member’s current health benefit plan.

Correction or repair of complications and revisions are considered not medically necessary when the original surgery was not medically necessary, except when the complication is causing or is likely to cause a medical or surgical emergency. Self-funded ERISA group plans may have different terms; refer to member contract language for those groups.

Surgery to correct or repair complications of previously authorized gender transition/affirmation surgery is considered medically necessary only when documentation identifies specific complications that cause pain, functional impairment, significant deformity, or are likely to cause a serious medical or surgical condition. Absent such documentation, correction/repair requests may be denied.

Procedures performed solely for cosmetic reasons — those intended only to change or improve appearance and not to restore or improve body function — are not medically necessary under this policy. When a procedure could be for cosmetic reasons, coverage determination is governed by the member’s plan terms.

Gender transition/affirmation surgery for minors (under 18 years) is considered not medically necessary under this policy; the evidence base for irreversible surgical interventions in children and adolescents is limited and insufficient according to multiple reviews, and the policy retains an age threshold of 18 years for most covered surgeries.

Reversal of previously performed gender transition/affirmation surgery is considered not medically necessary when the original surgery was determined to be not medically necessary, except when a complication is causing or is likely to cause a medical or surgical emergency. If the original surgery was performed while the individual was not covered by the plan, coverage for reversal is dependent on whether the original surgery is eligible for coverage under the member’s current health benefit plan.

Procedure, Diagnosis, and Billing Codes

Listed CPT codes (partial list in this document section)CPT

11920	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less
11921	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm
11922	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure)
11950	Subcutaneous injection of filling material (e.g., collagen); 1 cc or less
11951	Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc
11952	Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc
11954	Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc
15771	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
15772	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (list separately in addition to code for primary procedure)
15773	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate

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HCPCS and ICD-10-PCS codes (partial list)mixed

C1813	Prosthesis, penile, inflatable
C2622	Prosthesis, penile, noninflatable
L8600	Implantable breast prosthesis, silicone or equal
L8699	Prosthetic implant, not otherwise specified
0U5J0ZZ	Destruction of Clitoris, Open Approach
0U5JXZZ	Destruction of Clitoris, External Approach
0U9J00Z	Drainage of Clitoris with Drainage Device, Open Approach
0U9J0ZZ	Drainage of Clitoris, Open Approach
0U9JX0Z	Drainage of Clitoris with Drainage Device, External Approach
0U9JXZZ	Drainage of Clitoris, External Approach

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ICD-10-PCS creation of genitalia codesICD-10-PCS

0W4M070	Creation of Vagina in Male Perineum with Autologous Tissue Substitute, Open Approach
0W4M0J0	Creation of Vagina in Male Perineum with Synthetic Substitute, Open Approach
0W4M0K0	Creation of Vagina in Male Perineum with Nonautologous Tissue Substitute, Open Approach
0W4M0Z0	Creation of Vagina in Male Perineum, Open Approach
0W4N071	Creation of Penis in Female Perineum with Autologous Tissue Substitute, Open Approach
0W4N0J1	Creation of Penis in Female Perineum with Synthetic Substitute, Open Approach
0W4N0K1	Creation of Penis in Female Perineum with Nonautologous Tissue Substitute, Open Approach
0W4N0Z1	Creation of Penis in Female Perineum, Open Approach

Coding updates and historical codes mentionedmixed

19318	CPT code added (per history entry)
19303	CPT code added (per history entry)
19350	CPT code added (per history entry)
53430	CPT code added (per history entry)
19342	CPT code added (per history entry)
19357	CPT code added (per history entry)
19304	CPT code added (per history entry)
58570	CPT code added then removed per history entries
58150	ICD-9 procedure code removed per history

Historically added/modified CPT and HCPCS codes in this section of the policymixed

11920	11920 (listed in added CPT codes)
11921	11921
11922	11922
11950	11950
11951	11951
11952	11952
11954	11954
11960	11960 (removed later)
15771	15771 (added)
15772	15772 (added)

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Added CPT CodesCPT

21615	Added CPT code (exact description not provided in chunk)
21811	Added CPT code (exact description not provided in chunk)
21899	Added CPT code (exact description not provided in chunk)

Added HCPCS CodesHCPCS

L8600	Added HCPCS code (exact description not provided in chunk)
L8699	Added HCPCS code (exact description not provided in chunk)

Inpatient site-of-service criteria — clinical thresholds for inpatient vs outpatient

Primary medically necessary outpatient sitesOff-campus outpatient hospital/medical center; On-campus outpatient hospital/medical center; Ambulatory surgical center (ASC)

Inpatient site justified whenPatient has clinical condition placing them at increased risk for complications (examples: anesthesia risk, ASA class III or higher, prolonged surgery >3 hours, personal history of anesthesia complications)

Additional inpatient risk factorsSignificant cardiovascular, pulmonary, renal or hepatic disease (e.g., recent MI <3 months, uncompensated CHF NYHA III/IV, COPD with FEV1 <50%), morbid obesity (BMI ≥50), pregnancy, bleeding disorder, anticipated need for transfusion(s)

Autologous fat graft injectate thresholds — CPT-specific injectate volume thresholds

Prior Authorization, Documentation, and Administrative Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for genital surgery-related hair removal and for many gender transition/affirmation surgeries. Verify member contract language or call customer service to determine plan-specific coverage, exclusions, or customized criteria before scheduling services.

Prior authorization required for hair removal when done in preparation for genital surgery.
Some plans exclude some or all gender transition/affirmation services; confirm member contract benefits.
Facility and anesthesia charges related to covered surgery are included when the procedure is covered by the individual's plan.

Prior Authorization

Authorization validity and mental health recertification

Authorizations for surgeries and procedures are valid for 12 months from the date of authorization. If an authorized procedure is not completed within 12 months, a new authorization must be requested. If a previously authorized surgery requiring a mental health recommendation is requested or performed within two years of the prior authorization, a new mental health recommendation is not required; beyond two years a new mental health recommendation is required.

Background and Rationale

Gender transition/affirmation surgery alters physical sexual characteristics to align with an individual’s identified gender and is typically performed after diagnosis of gender dysphoria and multidisciplinary assessment. Typical procedures include chest/breast surgery (mastectomy, augmentation, reduction), genital surgery (e.g., vaginoplasty, phalloplasty), facial and body feminization/masculinization, hair removal, voice-related procedures, and related ancillary services. These interventions are often irreversible and are part of a long-term diagnostic and treatment plan requiring mental health evaluation and appropriate documentation.

Key Definitions

Gender transition/affirmation surgery — definition

DefinitionSurgical procedures that change sexual characteristics (genitals, breasts, and sometimes face or trunk) so they align with the individual's identified gender

Clinical contextUsually final steps in a long-term diagnostic and therapeutic process after diagnosis of gender dysphoria, counseling, and preparation for hormone therapy when desired

ReversibilityThese procedures are often irreversible and thus require multidisciplinary evaluation and readiness assessment

Gender Dysphoria (DSM-5) — definition

DSM-5 definition (summary)Marked incongruence between experienced/expressed gender and assigned gender for at least 6 months, manifested by specified criteria and associated with clinically significant distress or impairment

Manifestations include

Policy Updates and Revision History

2026-02-23Interim review approvalLatest

Interim review approved clarifying that for hair removal either current or past confirmation of Gender Dysphoria and either current or past verification that diagnostic criteria are met are acceptable; added language about complications likely to cause functional impairment or serious medical/surgical condition for revision/reversal surgery.

2025-10-01Coding update effective

Added CPT codes 21615, 21811, 21899 and HCPCS codes L8600 and L8699 effective October 1, 2025.

2025-12-09

Policy Summary

PayerPremera Bluecross

PolicyGender Transition/Affirmation Surgery and Related Services

Policy CodePolicy N/A

Change TypeInterim clarifications and code additions

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionVerify benefits and obtain required mental health recommendation documentation (one dated evaluation within 12 months) and prior authorization when applicable.

SourceLink

On This Page

Prior Authorization

Authorization expectations for repairs and revisions

For repairs, revisions, or reversal of previously authorized surgeries, prior authorization expectations mirror initial surgery authorizations. Document the complication and the clinical need for revision or reversal; if the original surgery was determined to be not medically necessary, revisions/reversals are generally considered not medically necessary except in emergencies or where the member contract specifies otherwise.

Prior authorization is implied/expected for revisions, repairs, or reversals of previously authorized gender transition/affirmation surgery.
Provide documentation of specific complications causing pain, functional impairment, or significant deformity to support coverage of corrective surgery.
Revisions/corrections are considered not medically necessary if the original surgery was not medically necessary, except for emergencies or as defined by member contract.

Documentation Required

Verify benefits and obtain required mental health recommendations

Verify benefits and obtain any required mental health recommendations before submitting authorization requests. Confirm whether the member's plan has customized criteria or exclusions that modify coverage or documentation requirements.

Check member contract language or contact customer service to determine covered surgeries and any plan-specific exclusions.
Some self-funded or employer-sponsored plans may have different benefits or exclusions; confirm plan-level customization.
Obtain required mental health recommendation(s) consistent with plan timing and content requirements when applicable.

Prior Authorization

Prior authorization timing for mental health recommendations

A new mental health recommendation is not required for any authorized procedure requested or completed within the policy's specified time windows: specifically, within two years of a prior authorization that had a qualifying mental health recommendation and within the 12-month authorization period. If the prior authorization lapses or the two-year window is exceeded, obtain a new qualifying mental health recommendation.

No new mental health recommendation needed if procedure is requested/done within two years of a prior authorized procedure that had a qualifying recommendation.
If >2 years since prior authorization (or prior qualifying recommendation), obtain new mental health recommendation.
Authorizations themselves remain valid 12 months; if authorization expires, a new authorization request is required even if within the two-year mental health window.

Documentation Required

Fertility preservation prerequisite

Preservation of fertility procedures (sperm, oocyte, embryo procurement and cryopreservation) performed prior to gender transition/affirmation surgery are considered medically necessary unless the individual's plan specifically excludes assisted reproduction services. Confirm member contract language.

Fertility preservation covered prior to gender surgery except when plan excludes assisted reproduction benefits.
Verify member contract for any exclusions or limitations.

Note

Hormone therapy not required

A trial of hormone therapy is not required prior to mastectomy, augmentation mammoplasty, or genital surgery. Prior requirements for pre-surgery hormone therapy have been removed for these procedures.

Hormone therapy is not a pre-requisite for mastectomy, augmentation mammoplasty, or genital surgery.
Previous policy requirements for pre-surgery hormone therapy have been rescinded based on updated evidence and policy revision.

Note

Hormone therapy prior to surgery

Hormone therapy prior to certain surgeries (previously required in some cases) is no longer mandated by this policy; clinicians should follow current plan criteria and clinical judgment when planning surgery.

Policy no longer mandates hormone therapy prior to augmentation mammoplasty or genital surgery.
Consider clinical risks/benefits of hormone therapy for individual patients; hormone therapy may still be part of overall treatment but is not a coverage precondition.

Documentation Required

Required documentation for all requests

One or more documentation elements are required for all authorization requests. Medical records must explicitly document how the patient meets each specific medical necessity criterion applicable to the requested surgery or procedure. Generic statements that WPATH standards are met are insufficient.

Medical records must document all specific medical necessity criteria listed in the policy or in any plan-customized criteria.
For procedures that require mental health recommendations, include a dated letter or medical record documentation from a licensed mental health professional with the minimum required content and dates of evaluation within the prior 12 months.
For hair removal prior to genital surgery, document the body area(s) targeted (existing genital sites or donor tissue) and the timing relative to planned genital surgery.

Documentation Required

Medical tattooing documentation

Medical tattooing is covered only when performed in conjunction with or after an authorized procedure and when intended to result in a more feminine, masculine, or non-binary appearance. The purpose must be clearly documented and the provider must be appropriately licensed.

Medical tattooing must be done in conjunction with or after an authorized surgery or procedure, or meet coverage criteria otherwise.
Documentation must state the intent to improve gender appearance and show no indication the tattooing is for unrelated cosmetic reasons.
Permitted providers include licensed healthcare providers, state licensed tattoo artists, or state licensed cosmetic artists.

Note

Contract exclusions/plan customization

Coverage and applicability of services depend on the member's contract and plan benefits. Some plans include broad coverage for gender transition/affirmation services while others have exclusions or customized criteria. Always verify benefit eligibility prior to authorization.

Refer to member contract language or customer service to determine covered services and any plan-specific exclusions.
Some employer-sponsored or self-funded plans may exclude some or all gender transition/affirmation services.

Qualifying mental health recommendation — definition

DefinitionA recommendation from a licensed mental health professional that supports the specific surgery and includes dates of recent evaluation or treatment within the last 12 months (or frequency demonstrating evaluation within 12 months)

Required contentMust confirm diagnosis of Gender Dysphoria, verify diagnostic criteria are met, document persistence or preparatory actions (e.g., hormones, living in role), and verify capacity to consent and control of comorbid conditions

Form acceptableOne letter of recommendation or equivalent medical record documentation from a qualified clinician based on evaluation or psychotherapy

Revision/Correction — definition and note that these may be not medically necessary when original surgery not medically necessary

DefinitionRevision/Correction: revision, correction of incomplete or incorrectly done surgery, or correction/repair of complications

Policy note on medical necessitySuch procedures may be considered not medically necessary when the original surgery was determined to be not medically necessary, except when an emergency or potential emergency exists or when a complication is causing or likely to cause a serious medical/surgical condition

Documentation requirementCoverage requires documentation that the prior surgery was incomplete/incorrect or that specific complications warrant correction and that repair is expected to improve function or reduce significant deformity

Recent material changes: effective 03/01/2026 (Interim Review approved 02/23/2026) clarified acceptable timing for diagnostic confirmation for hair removal: either current or past confirmation of Gender Dysphoria and either current or past verification that diagnostic criteria are met are acceptable. Coding updates effective 10/01/2025 added CPT codes 21615, 21811, 21899 and HCPCS codes L8600 & L8699. The policy also revised timing rules so that prior qualifying surgeries need not have been covered at the time they were performed; coverage availability is determined by the member’s current health benefit plan.