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ModifiedPremera Blue Cross of WashingtonPolicy N/A

Gender-Affirming Surgery and Related Services

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Coverage criteria and medical-necessity review for gender transition/affirmation surgeries, modifications to prior surgery, hair removal, medical tattooing, fertility preservation, and related services. Coverage depends on the member contract and applies to feminization, masculinization, and non-binary transition services.

Policy Summary

PayerPremera Blue Cross of Washington

PolicyGender-Affirming Surgery and Related Services

Policy CodePolicy N/A

Change TypeModified

Effective DateNovember 1, 2026

Last ReviewNov 1, 2026

Next Review DateN/A

Key ActionConfirm through the member contract or customer service that the requested gender transition/affirmation service is covered, then submit the request for medical-necessity review.

SourceLink

POLICY UPDATE CHANGES

The prior requirement for hormone therapy before augmentation mammoplasty is no longer considered necessary.

Uterine transplantation and penile transplantation are considered investigational for gender transition/affirmation.

Coverage for certain non-breast/chest, non-genital, additional breast augmentation, and cosmetic procedures is mandated for Washington-regulated health plans beginning in 2022.

The policy added separate sections stating that uterine transplantation and penile transplantation for gender transition/affirmation are investigational.

The policy revised mental-health recommendation requirements, including allowing recommendations or support through letters or medical-record documentation and changing the timing requirement from 6 months to 12 months before the request.

The policy removed hormone therapy as a prerequisite for initial augmentation mammoplasty.

The policy removed the requirement for a pre-surgery or pre-procedure surgeon or other provider evaluation for all surgeries and procedures.

The policy expanded and clarified eligibility and documentation requirements for hair removal related and unrelated to genital surgery.

The policy added criteria for revising appearance, correcting incomplete or incorrectly performed surgeries, reversing prior surgery, and correcting complications.

The policy clarified that additional breast augmentation, breast/chest procedures, and genital procedures may be evaluated under criteria for feminization, masculinization, or non-binary transition rather than being categorically treated as cosmetic.

The policy added site-of-service medical-necessity review for breast reduction, laparoscopic-assisted vaginal hysterectomy, rhinoplasty, and vaginal hysterectomy.

The requirement for letters of recommendation, support, or medical-record documentation from non-independently licensed mental health clinicians to be co-signed by an independently licensed master's- or doctoral-level mental health professional was removed.

Documentation from Associate or limited-license mental health professionals was expressly included among acceptable letters of recommendation, support, or medical-record documentation.

CPT codes 21615, 21811, and 21899 and HCPCS codes L8600 and L8699 were added to the policy coding information effective October 1, 2025.

ICD-10-PCS codes 0W4M0Z0 and 0W4N0Z1 were deleted because they were inactive as of October 1, 2018.

18+Minimum age for most gender-affirming surgery and hair-removal criteria

12 monthsMental-health documentation lookback period

12 monthsAuthorization validity period

InvestigationalUterine and penile transplantation coverage status

NoneHormone therapy prerequisite for specified surgeries

1 letterMinimum mental-health recommendation requirement for specified surgeries

Coverage Criteria

General covered gender-affirming surgical services

Covered when the member contract covers the service and all applicable criteria are met.

General surgical criteria: The requested surgery is for feminization, masculinization, or non-binary transition; an individualized recommendation or support letter or medical-record documentation is provided by a qualified licensed mental-health professional; the documentation is based on evaluation, psychotherapy, or mental-health treatment within the applicable 12-month period; gender dysphoria is confirmed; and the individual is at least 18 years old.Age ≥ 18; documentation within 12 months

Member contract coverage and exclusions apply.

Covered surgical services

Examples of services considered medically necessary when applicable criteria and member contract coverage are satisfied.

Surgical service categories: Breast/chest surgery may include mastectomy or breast reduction for female-to-male or female-to-non-binary/gender-neutral transition and augmentation mammoplasty or lipofilling for male-to-female transition. Genital and related procedures may include clitoroplasty, hysterectomy, labiaplasty, metoidioplasty, orchiectomy, penectomy when applicable, penile prostheses, phalloplasty, testicular prostheses, salpingo-oophorectomy, scrotoplasty, urethroplasty, vaginectomy, and vaginoplasty. Additional covered categories may include breast augmentation after initial augmentation, non-breast/chest, non-genital, hair transplantation/grafting, and other feminization, masculinization, or non-binary procedures when covered by the plan.

Policy Summary

PayerPremera Blue Cross of Washington

PolicyGender-Affirming Surgery and Related Services

Policy CodePolicy N/A

Change TypeModified

Effective DateNovember 1, 2026

Last ReviewNov 1, 2026

Next Review DateN/A

Key ActionConfirm through the member contract or customer service that the requested gender transition/affirmation service is covered, then submit the request for medical-necessity review.

SourceLink

On This Page

The member contract determines which listed services are covered.

Hair removal related to genital surgery

Covered when all of the following are met.

Genital-surgery hair removal: Genital gender-affirmation surgery has been authorized under a Company plan within the prior 12 months, or current/past gender-dysphoria confirmation and DSM-criteria verification are documented; the individual is at least 18 years old; hair removal is from existing genital sites where surgery will be performed or from donor tissue to be used for female or male genital reconstruction; hair removal occurs in a clinic or office outside a hospital; and the service is performed by an appropriately licensed, certified, registered, or otherwise state-approved professional or facility.Age ≥ 18; prior authorization within 12 months when that pathway is used

Laser or electrolysis is addressed.

Facial, body, or extremity hair removal not related to genital surgery

Covered when all of the following are met and the member plan covers the service.

Non-genital hair removal: Surgery for gender affirmation has been authorized under a Company plan within the prior 12 months, or current/past gender-dysphoria confirmation and verification or demonstration of all DSM diagnostic criteria are documented; the individual is at least 18 years old; hair removal occurs in a clinic or office outside a hospital; the service is performed by an appropriately licensed, certified, registered, or otherwise state-approved professional or facility; and there is no indication that the service is for an unrelated cosmetic purpose.Age ≥ 18; prior authorization within 12 months when that pathway is used

If the location is not specified, the service is presumed to be facial, body, or extremity hair removal unrelated to genital surgery.

Medical tattooing

Covered when all of the following are met.

Medical tattooing is performed in conjunction with or after surgery or a procedure authorized under a Company plan or otherwise satisfying coverage criteria; it is intended and expected to result in a more feminine, masculine, or non-binary appearance; it is not being performed for an unrelated cosmetic purpose; and it is performed by a licensed healthcare provider, state-licensed tattoo artist, or state-licensed cosmetic artist.

Member contract language may alter coverage.

Revision of appearance after previous gender-affirmation surgery

Covered when all applicable criteria are met.

Revision pathways: Documentation from a treating or evaluating professional verifies that revision is expected to improve feminine, masculine, or non-binary appearance and decrease gender dysphoria; or a physical examination verifies a significant deformity that is not a component of normal anatomy; and there is no indication that the procedure is pursued for an unrelated appearance concern. If the original surgery occurred while the individual was not covered by a Company plan, coverage for the original surgery must be available under the current plan.

Revision is not medically necessary when the original surgery was not medically necessary, except for a complication causing or likely to cause a medical or surgical emergency.

Correction of incomplete or incorrectly performed surgery

Covered when all applicable criteria are met.

Correction criteria: A surgeon documents that previously authorized gender-affirmation surgery was incomplete or incorrectly performed and identifies the specific components omitted or performed incorrectly and requiring correction. If the original surgery occurred while the individual was not covered by a Company plan, coverage for the original surgery must be available under the current plan.

Applies to non-breast/chest, non-genital, additional breast augmentation, breast/chest, and genital procedures as addressed in the policy.

Reversal of gender-affirmation surgery

Generally not medically necessary except when all applicable exception criteria are met.

Reversal exceptions: Reversal of partially or fully completed gender-affirmation surgery may be medically necessary when there is a serious medical barrier to completing gender transition/affirmation or a serious medical condition necessitating reversal. If the original surgery was performed while the individual was not covered by a Company plan, coverage for the original surgery must be available under the current plan unless a complication is causing or likely to cause a medical or surgical emergency.

Reversal remains not medically necessary when the original surgery was determined not medically necessary, except for a qualifying emergency complication.

Correction or repair of complications

Covered when all applicable criteria are met.

Complication criteria: The complication of previously authorized gender-affirmation surgery causes pain or functional impairment, is likely to cause functional impairment, or constitutes or is likely to cause a serious medical or surgical condition. Revision, or reversal and redoing of the original procedure, must be required to correct or repair the complication. If the original surgery occurred while the individual was not covered by a Company plan, coverage for the original surgery must be available under the current plan unless the complication is causing or likely to cause a medical or surgical emergency.

Example: Baker IV contracture after breast augmentation requiring implant removal and replacement with smaller implants.

Fertility preservation

Covered when the plan includes the applicable assisted-reproduction benefit.

Preservation before surgery: Procurement, cryopreservation, and storage of sperm, oocytes, or embryos performed before gender transition/affirmation surgery are medically necessary for gender transition/affirmation.

Coverage does not apply under plans that do not include a benefit for assisted reproduction services.

Site of service

Use the most appropriate, safe, and cost-effective site; inpatient care requires qualifying clinical risk.

Medically necessary sites: For applicable elective surgical procedures, medically necessary sites include an off-campus outpatient hospital or medical center, an on-campus outpatient hospital or medical center, or an ambulatory surgical center. An inpatient hospital or medical center is medically necessary only when the patient has a documented increased risk for complications, including qualifying anesthesia, cardiovascular, liver, pulmonary, renal, pregnancy, obesity, bleeding, or transfusion risk.Examples include ASA III or higher, surgery >3 hours, BMI ≥50, MELD >8, COPD FEV1 <50%, or dialysis-dependent end-stage renal disease

Site-of-service criteria do not apply to IHS facilities; use procedure-only medical-necessity criteria for IHS.

Complications and revision or reversal

Revision, reversal, or repair is medically necessary when the stated complication criteria are met, subject to member contract terms.

Complication-related revision or reversal: The prior gender transition/affirmation surgery caused pain or functional impairment, is likely to cause functional impairment, or presents a serious medical or surgical condition; and revision, reversal, redoing, correction, or repair is required to address that condition.

If the original surgery was performed while the member was not covered, coverage additionally requires that the original surgery be covered under the current plan or that the complication causes or is likely to cause a medical or surgical emergency.

Fertility preservation

Fertility preservation performed before gender transition/affirmation surgery is medically necessary when the applicable benefit is available.

Fertility preservation: Procurement, cryopreservation, and storage of sperm, oocytes, or embryos are performed before gender transition/affirmation surgery for gender transition/affirmation.

The service is subject to plans that include a benefit for assisted reproduction services.

Mental health recommendation and psychiatric assessment

For procedures requiring a mental health recommendation, the documentation must contain all applicable elements below.

Mental health recommendation requirements

Required content: The recommendation supports the specific proposed surgery or gender transition/affirmation surgery generally; confirms Gender Dysphoria and the applicable DSM diagnostic criteria; documents persistence of gender incongruence or dysphoria or qualifying transition-related history; and, when recommending surgery, addresses that the decision is well thought out and that the individual has capacity to make a fully informed decision.
Psychiatric assessment: The decision to proceed is not a symptom or product of another mental disorder or condition; any other psychiatric disorders are reasonably well controlled and are not contraindications; and disorders that may impair reality testing are well stabilized with intact reality testing and are not contraindications.

DSM-5 Gender Dysphoria criteria

The DSM-based Gender Dysphoria description requires the duration criterion and at least two manifestations, together with clinically significant distress or impairment.

DSM-5 Gender Dysphoria framework: There is a marked incongruence between experienced/expressed gender and assigned gender for at least 6 months, the condition is associated with clinically significant distress or impairment, and at least two listed manifestations are present.At least 6 months; at least 2 manifestations

Listed manifestations include incongruence with primary or secondary sex characteristics, desire to be rid of assigned sex characteristics, desire for characteristics of another gender, desire to be another gender, desire to be treated as another gender, or conviction of having typical feelings and reactions of another gender.

Covered components and associated services

The policy provides procedure-specific coverage clarifications, subject to the member's contract and plan limitations.

Procedure-specific covered components: The requested service is a covered component or qualifying associated service under the applicable procedure category and plan terms.

Examples include nipple/areola reconstruction, chest contouring, chest liposuction, and nerve repair performed concurrently with covered mastectomy; liposuction performed concurrently with augmentation to harvest fat for grafting; mastopexy performed concurrently with augmentation; CT planning for medically necessary facial surgery; otolaryngology work-up before covered voice modification surgery; and local anesthesia or nerve block associated with covered hair removal.

Minimum age

Gender transition/affirmation surgery is considered medically necessary only at or above the stated minimum age.

Adult age requirement: The individual is at least 18 years old.>= 18 years

The policy states that the minimum age continues to be 18 years.

Diagnostic and multidisciplinary assessment

The policy describes a long-term multidisciplinary diagnostic process and lists the following features associated with true transsexualism under the cited standards of care.

Diagnostic and clinical features

Identity and distress: Permanent and profound identification with the opposite sex and persistent discomfort regarding biological sex or inadequacy in the gender role.
Desired physical congruence: Wish to make the body as congruent as possible with the preferred sex through surgery and hormone replacement.
Functional impact: Clinically relevant distress or impaired ability to function in social, work-related, or other situations.
Differential diagnosis: Not a symptom of another mental disorder or a chromosomal abnormality.
Duration: Persistent presence of the transsexual identity for at least 2 years.>= 2 years

Covered service categories

Coverage may include the following gender transition/affirmation services, subject to the member contract and plan-specific criteria.

Covered service categories: Mastectomy or breast reduction; augmentation mammoplasty; genital surgery; hair removal related to genital surgery; nonbreast/chest surgeries or procedures; non-genital surgeries or procedures; additional breast augmentation; hair removal not related to genital surgery; and breast/chest or genital cosmetic procedures, including related facility and anesthesia charges.

The benefit application states that Washington individual plans and most Washington employer-sponsored group plans provide this coverage; Alaska plans have a more limited list described in the policy.

Investigational procedures

The following procedures are considered investigational for gender transition/affirmation.

Investigational transplantation: Uterine transplantation or penile transplantation for gender transition/affirmation.

Penile transplantation is distinct from penile prostheses; the policy reports no penile transplantation for gender transition/affirmation and insufficient evidence for uterine transplantation.

Uterine and penile transplantation

Investigational for gender transition/affirmation.

Investigational transplantation: Uterine transplantation or penile transplantation for gender transition/affirmation.

These procedures are distinct from uterine procedures or penile prosthesis placement.

Revision, reversal, and correction of complications

Revision, reversal, or complication correction requires documentation that the prior surgery met criteria at the time it was performed.

Qualifying circumstances: Revision of appearance, incomplete or incorrectly performed surgery, reversal, or correction of complications may be evaluated when the policy's applicable criteria are met.

Documentation must address applicable significant deformity, serious medical or surgical condition, complication, or other qualifying circumstance.

Uterine and penile transplantation

Considered investigational.

Investigational transplant procedures: Uterine transplantation or penile transplantation for gender transition or affirmation.

Revision, correction, complication repair, and reversal

Coverage depends on satisfaction of applicable policy criteria and the member contract.

Revision, correction, complication repair, or reversal: The requested procedure must meet the applicable criteria for the service. Revisions, correction of incomplete or incorrectly performed surgery, correction or repair of complications, and reversal are generally not medically necessary when the original surgery was determined not medically necessary, except where an emergency or potential emergency applies and subject to member contract terms. Coverage may also depend on whether coverage for the original gender transition or affirmation surgery is available under the member's current health benefit plan.

Uterine transplantation and penile transplantation—distinct from penile prosthesis placement—are considered investigational for gender transition or affirmation because evidence is insufficient or absent. Penile transplantation has not been reported for this indication.

Hair removal must support gender-affirming feminization, masculinization, or non-binary transition and must involve an applicable genital, donor-tissue, facial, body, or extremity treatment area. Services pursued for unrelated appearance improvement, normal aging, celebrity resemblance, or another unrelated purpose are subject to applicable exclusions or other benefit rules.

Nipple or areola reconstruction, chest contouring, and chest liposuction are medically necessary components of covered mastectomy when performed at the same time. Liposuction may be covered when performed with augmentation mammoplasty to harvest fat, and mastopexy may be covered when performed concurrently with augmentation. When performed later, these services may be treated as masculinization, feminization, or cosmetic procedures and are subject to plan coverage or exclusions.

When the body area for hair removal is not specified, the service is presumed to be facial, body, or extremity hair removal rather than hair removal before genital surgery. The request should identify the treatment area when genital-surgery hair removal is intended.

Coverage may be limited by the member contract to a specific list of gender transition or affirmation surgeries and procedures. Confirm the applicable plan terms before requesting authorization, particularly for later-stage, additional, or cosmetic procedures.

Uterine transplantation and penile transplantation are considered investigational for gender transition or affirmation. This classification does not apply to penile prostheses, which are addressed separately under plan-specific coverage provisions.

Some plans exclude some or all gender transition or affirmation services. A plan may also specifically exclude penile prostheses or implants for all conditions; an exclusion limited to sexual dysfunction does not apply to gender dysphoria under this policy.

Uterine transplantation and penile transplantation are investigational for gender transition or affirmation and are not established covered services under this policy.

The policy separately identifies uterine and penile transplantation as investigational procedures for gender transition or affirmation.

Uterine transplantation and penile transplantation are considered investigational for gender transition or affirmation.

This policy does not apply to Medicare Advantage. Coverage for Medicare Advantage members must be evaluated under the applicable Medicare Advantage benefit and policy requirements.

Reversal of partially or fully completed gender transition or affirmation surgery is generally not medically necessary. An exception may apply when there is a serious medical barrier to completing transition or affirmation or a serious medical condition necessitating reversal.

Revision, correction, or repair is generally not medically necessary when the original surgery was determined not medically necessary. An exception may apply when a complication causes or is likely to cause a medical or surgical emergency.

Procedures, hair removal, and medical tattooing are not supported under these gender-affirming criteria when pursued for unrelated appearance improvement, reversal of normal aging, celebrity resemblance, or unrelated medical or surgical problems. A service potentially indicated for another reason may be evaluated under a different benefit.

Correction or repair of complications, revision due to complications, or reversal and redoing due to complications is generally not medically necessary when the original surgery was determined not medically necessary. An exception may apply when the complication causes or is likely to cause a medical or surgical emergency, subject to member-contract terms.

Gender transition or affirmation surgery is not considered medically necessary under this policy for individuals younger than 18 years.

Coding and Site-of-Service Rules

CPT: tattooing, fillers, grafting, dermabrasion, and abrasionCPT

11921	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm
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
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
15774	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof
15775	Punch graft for hair transplant; 1 to 15 punch grafts
15776	Punch graft for hair transplant; more than 15 punch grafts

1–10 of 16

1/2

CPT: skin, facial, body-contouring, and epilation proceduresCPT

15788	Chemical peel, facial; epidermal
15789	Chemical peel, facial; dermal
15792	Chemical peel, nonfacial; epidermal
15793	Chemical peel, nonfacial; dermal
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

1–10 of 28

1/3

CPT: breast, facial, neck, thorax, and body-contouring proceduresCPT

17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue
19303	Mastectomy, simple, complete
19318	Breast reduction
19325	Mammaplasty, augmentation; with prosthetic implant
19340	Insertion of breast implant on same day of mastectomy
19342	Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19350	Nipple/areola reconstruction
19357	Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion
21087	Impression and custom preparation; nasal prosthesis
21120	Genioplasty; augmentation

1–10 of 25

1/3

CPT and HCPCS: facial, laryngeal, genital, reproductive, and prosthesis proceduresmixed

30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
30410	Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
30420	Rhinoplasty, primary; including major septal repair
30430	Rhinoplasty, secondary; minor revision
30435	Rhinoplasty, secondary; intermediate revision
30450	Rhinoplasty, secondary; major revision
31599	Unlisted procedure, larynx
31899	Unlisted procedure, trachea, bronchi
40500	Vermilionectomy (lip shave), with mucosal advancement
40510	Excision of lip; transverse wedge excision with primary closure

1–10 of 45

1/5

HCPCS prosthesis and implant codesHCPCS

C2622	Prosthesis, penile, noninflatable
L8600	Implantable breast prosthesis, silicone or equal
L8699	Prosthetic implant, not otherwise specified

ICD-10-PCS proceduresICD-10

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
0UBJ0ZX	Excision of Clitoris, Open Approach, Diagnostic
0UBJXZX	Excision of Clitoris, External Approach, Diagnostic
0UBJXZZ	Excision of Clitoris, External Approach, Excision of Clitoris, External Approach, Diagnostic, Drainage of Clitoris with Drainage Device, External Approach
0UCJ0ZZ	Extirpation of Matter from Clitoris, Open Approach, Excision of Clitoris, External Approach, Drainage of Clitoris, External Approach

1–10 of 49

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Gender transition/affirmation surgery procedure codesICD-10

0VUS4JZ	Supplement Penis with Synthetic Substitute, Percutaneous Endoscopic Approach
0VUS4KZ	Supplement Penis with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach
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
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

Place of Service (Professional Claims Codes)mixed

19	Off-Campus-Outpatient Hospital
21	Inpatient Hospital
22	On Campus-Outpatient Hospital
24	Ambulatory Surgical Center

Historical CPT coding updatesCPT

11920	CPT code listed in historical coding update
11921	CPT code listed in historical coding update
11922	CPT code listed in historical coding update
11950	CPT code listed in historical coding update
11951	CPT code listed in historical coding update
11952	CPT code listed in historical coding update
11954	CPT code listed in historical coding update
11960	CPT code listed as added historically; later removed
15771	CPT code added in coding update
15772	CPT code added in coding update

1–10 of 85

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Historical HCPCS coding updatesHCPCS

C1813	HCPCS code added in historical coding update
C2622	HCPCS code added in historical coding update

Additional historical CPT codesCPT

58260	CPT code added in historical coding update
58262	CPT code added in historical coding update
58290	CPT code added in historical coding update
58291	CPT code added in historical coding update

Added CPT codesCPT

21615	CPT code; description not provided in this window
21811	CPT code; description not provided in this window
21899	CPT code; description not provided in this window

Added HCPCS codesHCPCS

L8600	HCPCS code; description not provided in this window
L8699	HCPCS code; description not provided in this window

Deleted inactive ICD-10-PCS codesICD-10Not Covered

0W4M0Z0	ICD-10-PCS code deleted as inactive
0W4N0Z1	ICD-10-PCS code deleted as inactive

Prolonged surgery

ThresholdMore than 3 hours

Morbid obesity

ThresholdBMI ≥ 50

Advanced liver disease

ThresholdMELD score > 8

Chronic obstructive pulmonary disease

ThresholdFEV1 < 50%

Poorly controlled asthma

ThresholdFEV1 < 80% despite treatment

Obstructive sleep apnea thresholds

Moderate obstructive sleep apneaAHI ≥ 15 and ≤ 30

Severe obstructive sleep apneaAHI ≥ 30

Recent myocardial infarction

ThresholdLess than 3 months

Recent cerebrovascular accident

ThresholdLess than 3 months

Cardiac ischemia risk thresholds

Drug-eluting stentPlaced less than 1 year ago

AngioplastyPerformed less than 90 days ago

Hypertension risk criterion

CriterionThree or more drugs to control blood pressure

Minimum surgery age

Minimum age18 years

Provider Submission and Authorization Actions

Prior Authorization

Confirm Plan Coverage and Request Review

Before submitting a request, verify that the member’s contract covers the proposed gender transition/affirmation service and request review when required.

Confirm whether the plan has customized criteria or exclusions.
Submit the request for medical-necessity review.

Documentation Required

Submit Required Supporting Documentation

Submit the records needed to establish that every applicable coverage criterion is met.

Include the applicable recommendation or medical-record documentation.
Provide procedure-specific medical-necessity documentation.

Prior Authorization

Request Site-of-Service Review When Applicable

Request site-of-service review for elective procedures subject to the site-of-service policy.

Review applies to breast reduction, laparoscopic-assisted vaginal hysterectomy, rhinoplasty, and vaginal hysterectomy.
An inpatient hospital site is medically necessary only when qualifying clinical risks are documented.
The inpatient site is not medically necessary when the policy’s risk criteria are not met; site-of-service review does not apply to IHS facilities.

Prior Authorization

12-Month Authorization Validity

An authorization is valid for 12 months from its authorization date.

Request a new authorization if the procedure is not completed within 12 months.

Documentation Required

Reuse of Qualifying Mental-Health Recommendation

A qualifying mental-health recommendation may support later procedures without repeating all diagnostic-history elements when the new request is within the applicable two-year period.

The prior recommendation must contain all required elements.
The two-year period runs from authorization of the first qualifying procedure.

Documentation Required

Document Diagnosis, Readiness, and Age

Document the diagnosis, readiness, and age requirements for the proposed surgery or procedure.

Include confirmation of gender dysphoria and applicable diagnostic criteria.
Document that the individual is 18 or older.
Include multidisciplinary evaluation and readiness information when applicable.

Documentation Required

Mental-Health Recommendation Timing

Ensure the mental-health recommendation or supporting medical-record documentation is based on a timely evaluation or treatment.

For prospective requests, the evaluation, psychotherapy, or treatment must occur within the preceding 12 months.
For retrospective requests, it must occur within the 12 months immediately preceding surgery.

Documentation Required

Hair Removal Related to Genital Surgery

For hair removal before genital surgery, document that treatment is limited to tissue involved in the planned surgery.

Identify existing genital sites where surgery will be performed.
Alternatively, identify donor tissue that will be used to form female or male genitals.

Prior Authorization

Authorization Valid for 12 Months

A new authorization is required when an authorized surgery or procedure is not done or completed within 12 months.

All requirements generally must be satisfied for the new request.
Apply the limited mental-health-recommendation exception only when the timing rules are met.

Documentation Required

Timing of Mental-Health Recommendations

Apply the two-year timing rules when a prior authorized procedure included a qualifying mental-health recommendation.

A new recommendation is generally required when the request is more than two years after the prior authorization.
Within two years, a new recommendation may not be required, including for different procedures or staged surgery.
When a new recommendation is required, include the current required content; previously established diagnostic-history elements may be omitted as allowed.

Documentation Required

Mental-Health Recommendation and Diagnosis

For procedures requiring mental-health support, submit an individual-specific recommendation or medical-record documentation confirming gender dysphoria and the applicable diagnosis.

Use a recommendation from a qualified licensed mental-health professional.
Document the evaluation or treatment date or qualifying frequency within the preceding 12 months.
Confirm gender dysphoria and show that the applicable DSM criteria are met.

Documentation Required

Documentation Timing

The documentation date alone is insufficient; records must show when the individual was actually evaluated or treated.

State the date or dates within the preceding 12 months.
Alternatively, provide treatment frequency demonstrating evaluation or treatment during that period.

Documentation Required

Hair-Removal Documentation

Document the body area, purpose, setting, and qualified provider for hair-removal services.

Specify genital or donor-tissue sites for pre-genital-surgery hair removal.
For other hair removal, identify the facial, body, or extremity area and support feminization or non-binary transition.
Document that treatment occurs outside a hospital in an approved clinic or office and is performed by an approved provider.
A mental-health recommendation and pre-procedure evaluation are not required for hair removal.

Documentation Required

Revision, Correction, and Complication Records

For revision, correction, or complication-related surgery, submit records describing the prior procedure and the specific reason additional surgery is needed.

Document dissatisfaction or a significant deformity, incomplete or incorrect surgery, or a complication.
Show that the original procedure was authorized or that coverage for it is available under the current plan, as applicable.
Explain why the proposed procedure is medically necessary and not for an unrelated cosmetic purpose.

Documentation Required

Qualified Mental-Health Professionals

Recommendations, evaluations, psychotherapy, and treatment must be provided or documented by an eligible state-licensed mental-health professional.

Eligible professionals include master’s- or doctoral-level clinicians, psychiatric nurse practitioners, psychiatric physician assistants, and psychiatrists.
Associate or limited-practice master’s- or doctoral-level clinicians may qualify when state licensed.
Services may be provided in person or virtually.

Documentation Required

Qualified Mental Health Professional

Use an individual-specific recommendation from a qualified mental-health professional; generic or templated letters do not satisfy the requirement.

The recommendation may support the specific proposed procedure or gender transition/affirmation surgery generally.
Identify the professional’s licensure and role.

Documentation Required

Required Mental Health Content

Include the required clinical content in each mental-health recommendation or supporting record.

Recommendation to proceed with the proposed surgery or procedure.
Recent evaluation or treatment date or qualifying frequency.
Confirmation of gender dysphoria and documentation of applicable DSM criteria.
History showing persistence of incongruence or transition-related actions, as applicable.
Assessment that the decision is informed, not driven by another uncontrolled condition, and that the individual has decision-making capacity.

Documentation Required

Revision Surgery Documentation

For revision surgery, document the specific prior procedure and why the proposed revision is medically necessary.

Show that the revision is expected to improve feminine, masculine, or non-binary appearance.
Show that it is expected to decrease gender dysphoria.

Documentation Required

Revision Surgery for Appearance and Dysphoria

For appearance revision after prior gender transition/affirmation surgery, provide professional documentation supporting the expected clinical benefit.

Document expected improvement in the appropriate gender-related appearance.
Document expected reduction in gender dysphoria.
If based on deformity, include physical-examination verification that it is significant and not normal anatomy.

Documentation Required

Reversal of Gender Transition or Affirmation

For reversal of partially or fully completed gender transition/affirmation surgery, document the serious medical basis for reversal.

Document a serious medical barrier to completing transition/affirmation or a serious medical condition necessitating reversal.
Address current-plan coverage of the original surgery when the original surgery was performed outside a Company plan.

Documentation Required

Complication Correction or Repair

For complication correction or repair, document the actual complication and its functional or medical impact.

Identify complications causing pain, functional impairment, significant deformity, or a serious medical or surgical condition.
Explain why correction or repair is required.

Documentation Required

Revision or Reversal of Previously Authorized Surgery

For revision or reversal-and-redo procedures, show that a complication requires changing the previously authorized procedure.

Document that correction or repair requires revision or undoing of the original genital or breast/chest procedure.
Include complications likely to cause functional impairment or a serious medical or surgical condition.

Documentation Required

Multidisciplinary Pre-Surgery Evaluation

Submit a multidisciplinary pre-surgery evaluation and evidence of diagnosis and readiness for irreversible treatment.

Include relevant medical, surgical, psychiatric, and psychological assessments.
Document counseling regarding treatment options, risks, and expected psychological adjustments.

Documentation Required

Mental Health Assessment and Recommendation

Obtain and submit the mental-health assessment and recommendation supporting the proposed surgery.

The assessment should address diagnosis, treatment options, psychological preparedness, and readiness.
Use an eligible licensed mental-health professional and meet the required timing and content rules.

Documentation Required

Hair-Removal Documentation

For hair removal, document the treatment site, provider qualifications, setting, and gender-affirming purpose.

Identify genital or donor-tissue sites when treatment is preparatory to genital surgery.
If the site is unspecified, it is presumed to be facial, body, or extremity hair removal not related to genital surgery.
Document an approved provider and clinic or office setting outside a hospital.
A mental-health recommendation is not required.

Documentation Required

Revision and Complication Documentation

For revisions or complication-related procedures, provide records supporting the prior surgery, the defect or complication, and the requested correction.

Document incomplete or incorrect components, significant deformity, pain, functional impairment, or serious medical risk.
Explain why revision, reversal, or reversal-and-redo is required.
Confirm the original surgery met applicable coverage requirements or is covered under the current plan, as applicable.

Documentation Required

Mental Health Recommendation Documentation

Submit complete, current mental-health recommendation documentation rather than a generic WPATH or diagnostic statement.

Document the specific history of gender incongruence and transition, persistence over time, and relevant actions.
Address comorbid conditions, reality testing when applicable, informed decision-making, and surgical readiness.
For updated recommendations, apply the applicable two-year timing exception and omit only elements expressly permitted.

Documentation Required

Hair Removal Provider Documentation

Ensure the hair-removal provider and facility meet the policy’s qualification requirements and document those qualifications.

Eligible providers include physicians, nurse practitioners, physician assistants, state-approved or licensed electrologists or aestheticians, medical electrologists, CPEs, and approved spas or clinics.
A medical clinic staffed by physicians, nurse practitioners, or physician assistants may be presumed to provide treatment through one of those practitioners.
For spas, document state licensing, certification, approval, or the qualifications of the individual performing treatment.

Unsupported block type: denial_risk

Denial Risk

Non-Gender-Related or Cosmetic Purpose

Document that the service is being performed for gender-affirming feminization, masculinization, or non-binary transition rather than an unrelated or purely cosmetic purpose.

Do not submit services intended solely to improve general appearance, reverse normal aging, emulate celebrities, or correct unrelated medical problems under this policy.
A different benefit may apply when the indication is unrelated to gender transition/affirmation.

Denial Risk

Transplantation Procedures

Do not submit uterine or penile transplantation as established medically necessary gender-affirmation services.

Uterine transplantation is investigational.
Penile transplantation, distinct from penile prostheses, is investigational.

Denial Risk

Revision of a Non-Covered Original Procedure

A revision of a non-covered original procedure is generally not medically necessary.

Document that the original surgery was authorized or that coverage for the original surgery is available under the current plan.
An exception may apply when a complication causes or is likely to cause a medical or surgical emergency.

Denial Risk

Generic WPATH Statement Is Insufficient

A general statement that WPATH criteria or standards are met is insufficient.

Document every specific medical-necessity criterion for the requested procedure.
For plans using customized WPATH criteria, document and satisfy each applicable WPATH criterion.

Denial Risk

Incomplete Mental Health Documentation

Incomplete mental-health documentation may result in denial even when a recommendation is submitted.

Do not rely on a letter date alone to establish recent evaluation or treatment.
Include diagnosis and DSM criteria, persistence or transition history, comorbidity assessment, informed decision-making, and capacity when required.

Denial Risk

Complications of Non-Medically Necessary Surgery

Complications of surgery that was not medically necessary are generally not covered under these criteria.

An exception may apply when the complication causes or is likely to cause a medical or surgical emergency.
Member contract terms control when they provide different complication coverage.

Denial Risk

Later-Stage or Cosmetic Treatment

Later-stage or cosmetic treatment must satisfy the applicable coverage category rather than being assumed to be part of the original surgery.

Later nipple reconstruction, chest contouring, mastopexy, or additional augmentation may be subject to separate criteria or cosmetic exclusions.
Submit a new request when the procedure is a new or additional service.

Denial Risk

Expired Authorization or Mental Health Timing

Do not rely on an expired authorization or an outdated mental-health recommendation.

Request new authorization after 12 months.
Obtain a new mental-health recommendation when the two-year timing exception does not apply.

Denial Risk

Patient Younger Than 18

Do not submit gender transition/affirmation surgery for an individual younger than 18 under these criteria.

Document that the individual is at least 18 years old.

Denial Risk

Investigational Transplantation

Uterine transplantation is investigational for gender transition/affirmation.

Do not request coverage as an established medically necessary procedure.

Denial Risk

Plan-Specific Exclusions

Plan-specific exclusions and customized criteria may change whether a service is covered.

Review the member contract and benefit booklet.
Contact customer service when the plan’s coverage is unclear.

Denial Risk

Investigational Transplantation

Penile transplantation, distinct from penile prostheses, is investigational for gender transition/affirmation.

Do not confuse penile transplantation with covered penile prostheses, which remain subject to plan terms.

Denial Risk

Exaggeration of Existing Features

Do not submit a procedure intended to significantly enhance or exaggerate features already clearly recognizable as feminine, masculine, or non-binary without addressing the applicable exclusion or cosmetic criteria.

Document the gender-affirming purpose and expected clinical benefit.
Address plan coverage for cosmetic or feminization/masculinization procedures.

Denial Risk

Authorization Expiration and Prior Medical Necessity

An authorization expires after 12 months, and prior medical necessity does not automatically carry forward to a new request.

Submit a new authorization when the procedure is not completed within 12 months.
Meet all requirements for each new request, subject only to the applicable mental-health timing exception.

Denial Risk

Investigational Transplant Procedures

Investigational transplant procedures are not established covered gender-affirmation services.

Penile transplantation is investigational.
Submit only when the request is for a distinct covered service, such as a penile prosthesis, and plan terms permit it.

Prior Authorization

Genital Surgery Prerequisites

Genital surgery requests must satisfy the mental-health recommendation, diagnosis, age, and other applicable medical-necessity requirements.

Submit one qualifying recommendation or supporting medical-record documentation when required.
Document gender dysphoria and that the individual is 18 or older.
A trial of hormone therapy is not a prerequisite for genital surgery.

Policy Background

Gender transition or affirmation surgery modifies genital, breast or chest, facial, trunk, or other physical characteristics to align with an individual's affirmed gender. The policy addresses surgical and related services for feminization, masculinization, and non-binary transition, with coverage subject to the member contract and applicable medical-necessity criteria. Because many procedures are difficult to reverse, care commonly includes diagnosis of gender dysphoria, counseling about treatment options, and preparation for hormone therapy or surgery when desired.

Definitions

Gender transition or affirmation

DefinitionThe process of changing the gender characteristics a person was born with to characteristics aligned with the gender the person identifies with.

Site of service

DefinitionThe location where a surgical procedure is performed, including an off-campus outpatient hospital or medical center, an on-campus outpatient hospital or medical center, an ambulatory surgical center, or an inpatient hospital or medical center.

Morbid obesity

DefinitionBMI greater than or equal to 50 for purposes of the inpatient site-of-service risk criteria.

Moderate to severe obstructive sleep apnea

ModerateAHI of at least 15 and no more than 30

SevereAHI of at least 30

Prolonged surgery

DefinitionSurgery expected to last more than 3 hours.

Gender Dysphoria

DefinitionA marked incongruence between experienced or expressed gender and assigned gender lasting at least 6 months, manifested by at least two specified features, and associated with clinically significant distress or impairment.

Qualifying mental health recommendation

DefinitionDocumentation from a licensed mental health professional that contains all required information in the policy's recommendations section.

Company plan

DefinitionAny plan offered by the health insurance company.

Cosmetic

DefinitionServices primarily intended to preserve or improve appearance. Cosmetic surgery reshapes body structures to change or improve appearance rather than improve functioning or restore a specific bodily function.

Gender

DefinitionThe perception of a person's sex on the part of society as male or female.

Gender dysphoria

DefinitionAn individual's affective or cognitive discontent with the assigned gender and the distress that may accompany incongruence between experienced or expressed gender and assigned gender.

Gender identity

DefinitionAn individual's personal sense of self as male or female.

Pre-surgery evaluation

DefinitionAn evaluation performed before surgery.

Transgender

DefinitionPeople whose gender identity is discordant with their anatomical sex.

Transsexual

DefinitionTransgender people who seek to make their perceived gender and/or anatomical sex conform to their gender identity through strategies such as dress, grooming, hormone use, and/or surgery.