ModifiedUnitedHealthcarePolicy BIP185.V

Gender Dysphoria (Gender Identity Disorder) Treatment (for California Only)

Policy governing coverage and benefit interpretation for treatment of gender dysphoria for UnitedHealthcare West California plans; applies to affected members, providers, and utilization review processes in California.

Policy Summary

PayerUnitedHealthcare

PolicyGender Dysphoria (Gender Identity Disorder) Treatment (for California Only)

Policy CodePolicy BIP185.V

Change TypeMaterial coverage addition — WPATH v8 Appendix E reconstructive procedures added

Effective DateOct 1, 2025

Next Review Date

Key ActionObtain prior authorization when required and document that treatment meets WPATH-aligned criteria and medical necessity per UnitedHealthcare procedures.

SourceLink

POLICY UPDATE CHANGES

Reconstructive procedures listed in WPATH Version 8, Appendix E are covered when applicable criteria are met for adults/adolescents.

MultiplePlan types in scope

HSC §§1367.042,1374.72,1374.721Statutory refs

RequiredParity & medical necessity

Prior authAuthorization process

IR >=90%

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3 itemsExplicit exclusions

Coverage Criteria & Statutory Requirements

Statutory coverage & access requirements

Statutory coverage obligations and access requirements for mental health and substance use disorder services under California law:

Health plan contracts issued, amended, or renewed on or after January 1, 2021 that provide hospital, medical, or surgical coverage must provide coverage for medically necessary treatment of mental health and substance use disorders under the same terms and conditions applied to other medical conditions (HSC §1374.72).

Medically necessary treatment means services or products addressing the specific needs of the patient for preventing, diagnosing, or treating an illness, injury, condition, or its symptoms that are: (i) in accordance with generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in type, frequency, extent, site, and duration; and (iii) not primarily for the economic benefit of the plan or for convenience (HSC §1374.72).

Plans shall not limit benefits for mental health and substance use disorders to short-term or acute treatment (HSC §1374.72).

If medically necessary services are not available in-network within required geographic and timely access standards, the plan must arrange coverage for out-of-network services and any medically necessary follow-up so that, to the maximum extent possible, those standards are met; enrollee cost sharing for out-of-network arrangements shall be no greater than for in-network services (HSC §1374.72(d)).

For compliance, a plan may provide required mental health and substance use disorder services through a separate specialized plan or mental health plan and is not required to obtain an additional license to do so (HSC §1374.72(f)).

Gender-affirming care criteria

Coverage for gender-affirming treatments is contingent on documented assessments meeting WPATH-aligned criteria; specific requirements differ for adults and adolescents.

Adults — Hormonal treatment

Gender incongruence is marked and sustained.
Meets diagnostic criteria for gender incongruence.
Demonstrates capacity to consent for the specific gender-affirming hormone treatment.
Other possible causes of apparent gender incongruence have been identified and excluded.
Mental health and physical conditions that could negatively impact the outcome have been assessed and risks and benefits discussed.

Coding & Clinical Standards

No CPT/ICD coding specified in this partmixed

No codes listed

WPATH-listed treatmentsmixedCovered

WPATH v8 Appendix C	Hormone treatments listed in WPATH, Version 8, Appendix C
WPATH v8 Appendix E	Surgical and reconstructive procedures listed in WPATH, Version 8, Appendix E
Puberty blocking agents (per WPATH)	Puberty blocking agents that are clinically indicated per WPATH
Voice lessons/therapy	Voice lessons and/or voice therapy (with or without surgery)

inv-05: Interrater reliability pass rate

Interrater reliability pass rate>= 90%

Required action if threshold not metImmediately remediate poor interrater reliability and perform interrater reliability testing for all new staff before unsupervised utilization review

Reporting requirementRun interrater reliability reports on how clinical guidelines are used with utilization management and parity compliance activities

Utilization Review, Prior Authorization, and Provider Responsibilities

Prior Authorization

Follow statute-aligned utilization review and medical necessity standards (California)

Utilization review and medical necessity determinations for mental health and substance use disorder services must be based on current generally accepted standards of care and the most recent specialty treatment criteria; utilization review processes (prospective, concurrent, or retrospective) are permitted if consistent with statute and may not apply more restrictive criteria than specialty sources. The plan must also sponsor education, make criteria and training materials available at no cost, track use of criteria, and conduct interrater reliability testing.

Base medical necessity determinations on current generally accepted standards of mental health and SUD care and on the most recent specialty treatment criteria (HSC §1374.721(a)-(b)).
Do not apply different, additional, conflicting, or more restrictive criteria for level-of-care or patient care decisions than those specialty sources, except as allowed for out-of-scope or new technologies developed in accordance with §1374.721(a)-(d).
Participate in or be aware of the plan-sponsored education programs; plans must provide criteria and training materials at no cost and track criteria use and appeals (HSC §1374.721(e)(1)-(4)).
Expect that the plan will conduct interrater reliability testing to ensure consistency in utilization review decision making (HSC §1374.721(e)(5)).

Defined Terms

inv-08: Generally accepted standards of care

DefinitionStandards of care and clinical practice generally recognized by providers in relevant specialties (psychiatry, psychology, addiction medicine, counseling, etc.) including peer-reviewed literature, professional society guidelines, and FDA drug labeling

Sources considered validPeer-reviewed scientific studies, clinical practice guidelines, recommendations of nonprofit professional associations and specialty societies, and federal agency guidance

ScopeApplies to standards for diagnosis, prevention, and treatment of mental health and substance use disorders used in medical necessity determinations

inv-09: Utilization review

DefinitionProspective, retrospective, or concurrent review and approval, modification, delay, or denial of requests based in whole or in part on medical necessity; includes evaluation of appropriateness, level of care, intensity, efficacy, or efficiency

Policy Summary

PayerUnitedHealthcare

PolicyGender Dysphoria (Gender Identity Disorder) Treatment (for California Only)

Policy CodePolicy BIP185.V

Change TypeMaterial coverage addition — WPATH v8 Appendix E reconstructive procedures added

Effective DateOct 1, 2025

Next Review Date

Key ActionObtain prior authorization when required and document that treatment meets WPATH-aligned criteria and medical necessity per UnitedHealthcare procedures.

SourceLink

On This Page

Member understands effects on reproduction and has explored reproductive options.

Adults — Surgical treatment

Gender incongruence is marked and sustained.
Meets diagnostic criteria for gender incongruence.
Demonstrates capacity to consent for the specific gender-affirming surgical intervention.
Understands effects of surgical intervention on reproduction and has explored reproductive options.
Other possible causes of apparent gender incongruence have been identified and excluded.
Mental health and physical conditions that could negatively impact the outcome have been assessed and risks and benefits discussed.
Stable on gender-affirming hormonal regimen if indicated for the planned procedure (which may include at least 6 months of hormone treatment unless hormone therapy is not desired or is medically contraindicated).

Adults — Detransition or retransition

Documentation of a comprehensive multidisciplinary assessment by health care professionals experienced in transgender health.
Exploration of concerns with previous physical changes and efforts to avoid replication by further changes.
Recommended period of living in role before further physical changes are recommended.
Evaluation of the etiology of regret, if applicable, and the temporal stability of the surgical request.

Adolescents — Puberty blockers

Gender diversity/incongruence is marked and sustained over time.
Meets diagnostic criteria of gender incongruence.
Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.
Mental health concerns that may interfere with diagnostic clarity, capacity to consent, or treatment have been addressed sufficiently to proceed.
Informed of reproductive effects, including potential loss of fertility, and available fertility preservation options.
Reached Tanner stage 2.

Adolescents — Hormonal treatment

Gender diversity/incongruence is marked and sustained over time.
Meets diagnostic criteria of gender incongruence.
Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.
Mental health concerns that may interfere with diagnostic clarity, capacity to consent, or treatment have been addressed sufficiently to proceed.
Informed of reproductive effects, including potential loss of fertility, and available fertility preservation options.
Reached Tanner stage 2.

Adolescents — Surgical treatment

Gender diversity/incongruence is marked and sustained over time.
Meets diagnostic criteria of gender incongruence.
Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.
Mental health concerns that may interfere with diagnostic clarity, capacity to consent, or treatment have been addressed sufficiently to proceed.
Informed of reproductive effects, including potential loss of fertility, and available fertility preservation options.
At least 12 months of gender-affirming hormone therapy (or longer if required) for listed procedures unless hormone therapy is not desired or is medically contraindicated.

Services covered when applicable criteria are met

Hormone treatments listed in WPATH Version 8 Appendix C are covered.
Surgical and reconstructive procedures listed in WPATH Version 8 Appendix E are covered.
Puberty blocking agents clinically indicated per WPATH are covered.
Voice lessons and/or voice therapy (with or without surgery) are covered.

Explicit exclusions

Drugs for hair loss are not covered.
Drugs for sexual performance for members who have undergone genital reconstruction are not covered.
Drugs or devices not approved by the FDA for use in the United States are not covered.

Billing Rule

Obtain prior authorization from UnitedHealthcare or its delegate; verify EOC/SOB

Prior authorization for medically necessary gender dysphoria services must be obtained through UnitedHealthcare or delegated providers as determined by UnitedHealthcare; when coverage language conflicts with a member's Evidence of Coverage/Schedule of Benefits, the EOC/SOB governs.

Submit prior authorization requests to UnitedHealthcare or its delegated reviewers per UnitedHealthcare determination (Important Notes).
Verify member-specific coverage, limits, and exclusions against the member's EOC/SOB because the EOC/SOB governs in case of discrepancy (Instructions for Use).

ApplicabilityApplies to all health care services and benefits for diagnosis, prevention, and treatment of mental health and substance use disorders covered by a health care service plan contract; includes entities performing utilization review on plan's behalf

Prior authorization governancePrior authorization of medically necessary services must be done by UnitedHealthcare or delegated providers as determined by UnitedHealthcare; follow member Evidence of Coverage/Schedule of Benefits if discrepant

inv-10: Utilization review criteria definition

Utilization review criteria (definition)Any criteria, standards, protocols, or guidelines used by a health care service plan to conduct utilization review

Development requirementCriteria and medical necessity determinations must be based on current generally accepted standards of mental health and substance use disorder care

Use of specialty treatment criteriaPlans must apply criteria and guidelines set forth in the most recent versions of treatment criteria developed by the nonprofit professional association for the relevant clinical specialty when conducting utilization review

Restrictions on differing criteriaPlans shall not apply different, additional, conflicting, or more restrictive utilization review criteria than the specified specialty sources unless criteria were developed in accordance with the generally accepted standards