CurrentUnitedHealthcarePolicy BIP197.N

Gender Dysphoria Gender Identity Disorder Treatment Wa

Defines UnitedHealthcare's coverage criteria for gender-affirming hormonal and surgical treatments for adults and adolescents in Washington state, referencing state mandates and required documentation and provider qualifications. Specifies covered procedures, clinical criteria, prior authorization requirement, and a limited 'Not Covered' item list.

Policy Summary

PayerUnitedHealthcare

PolicyGender Dysphoria Gender Identity Disorder Treatment Wa

Policy CodePolicy BIP197.N

Change TypeRevisions to prior auth, criteria, and Not Covered list

Effective DateApr 1, 2026

Next Review Date

Key ActionPrior authorization of medically necessary services must be done by UnitedHealthcare or delegated providers as determined by UnitedHealthcare.

SourceLink

POLICY UPDATE CHANGES

Added reference link to the Medical Benefit Drug Policy titled Gonadotropin Releasing Hormone Analogs; removed reference link to Medications and Off-Label Drugs policy.

Revised language to state prior authorization must be done by UnitedHealthcare or delegated providers.

Revised Not Covered list to remove prior items and specify treatment received outside the United States is not covered.

25+Listed covered surgical/therapy items

18Criteria elements across adult/adolescent requirements

State-specific policy (Washington)

Coverage Summary

This policy implements Washington state non-discrimination and coverage requirements for gender-affirming treatment for UnitedHealthcare Commercial fully-insured and Individual Exchange fully-insured plans in Washington. It aligns coverage with medically necessary standards of care (including reference to WPATH) and federal parity and nondiscrimination requirements, and defines covered hormonal and surgical gender-affirming services. Coverage stance for applicable services is covered_with_criteria and prior authorization must be obtained through UnitedHealthcare or delegated providers.

Policy metadata and thresholds

Policy numberBIP197.N

SubjectGender Dysphoria (Gender Identity Disorder) Treatment (WA)

StatusCURRENT

ScopeUnitedHealthcare Commercial fully‑insured and Individual Exchange fully‑insured plans in Washington; defines coverage criteria for gender‑affirming hormonal and surgical treatments for adults and adolescents

Effective dateApril 1, 2026

Prior authorizationPrior authorization of medically necessary services must be done by UnitedHealthcare or delegated providers

Threshold - Breast augmentation hormone therapy duration12 months continuous hormone therapy prior to procedure

Threshold - Voice masculinization hormone therapy duration6 months continuous hormone therapy prior to surgery

Threshold - Genital surgery real-life experience12 months continuous full‑time real‑life involvement in identified gender

Threshold - Genital surgery hormone therapy duration12 months continuous hormone therapy appropriate for experienced gender (unless contraindicated)

Medical Necessity Criteria

Criteria for Adults - Hormonal treatment

Hormonal treatment for Gender Dysphoria may be indicated when ALL of the following are met, as documented in an assessment from a health care professional who has competencies in the assessment of transgender people:

ALL of the following

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

Provider Actions & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for medically necessary gender-affirming services. Prior authorization must be obtained from UnitedHealthcare or from delegated providers as determined by UnitedHealthcare before services are rendered.

Applies to surgical and non-surgical gender-affirming treatments and related services
Prior authorization determination may require submission of clinical assessments and supporting documentation

Documentation Required

Assessments & Qualified Healthcare Professional Documentation

Written clinical assessments from Qualified Healthcare Professionals (QHPs) experienced in treating Gender Dysphoria are required for specific procedures. The number of independent QHP assessments varies by procedure: at least one QHP assessment is required for breast surgeries and voice-related procedures; at least two independent QHP assessments are required for genital surgery. Assessments must document the clinical indications and that the individual meets the policy’s criteria.

Coding

Policy identifiersmixed

BIP197.N

UnitedHealthcare Policy Number (revision/version indicated in header)

Background, Evidence & Definitions

This policy references Washington Revised Code RCW 48.43.0128 regarding prohibited discrimination and coverage for gender-affirming treatment and the requirement that such treatment be covered when medically necessary and prescribed in accordance with accepted standards of care. The policy specifically cites alignment with the World Professional Association for Transgender Health (WPATH) Standards of Care (8th edition) as the reference guideline for clinical standards.

Type	Reference
Reference guideline	WPATH Standards of Care, 8th edition (2022)
Legal citation	RCW 48.43.0128 (WA) - Non-discrimination and coverage requirements for gender affirming treatment

Gender affirming treatment: A service or product prescribed to treat any condition related to the individual's gender identity when prescribed in accordance with generally accepted standards of care; must be medically necessary.

Qualified Healthcare Professional: Documented credentials from a relevant licensing board; minimum of a master's degree or equivalent training in a clinical field relevant to assessment/treatment of Gender Dysphoria; knowledge and experience in treating Gender Dysphoria.

Gender Dysphoria (Adolescents and Adults): DSM-5-TR diagnostic criteria summarized as a marked incongruence for at least 6 months manifested by specified criteria and associated with clinically significant distress or impairment.

Not Covered / Experimental

Not Covered: Treatment received outside the United States is explicitly not covered.

Policy revision history removed multiple prior Not Covered exclusions from earlier versions; the current Not Covered list has been revised to remove several prior items and now explicitly states that care received outside the United States is not covered.

Operational Thresholds

Operational thresholds (highlighted)

Breast augmentation hormone therapy duration12 months continuous hormone therapy prior to procedure

Voice masculinization (voice surgery) duration6 months continuous hormone therapy prior to surgery

Genital surgery real‑life experienceComplete at least 12 months of successful continuous full‑time real‑life involvement in the identified gender

Genital surgery hormone therapy durationComplete 12 months of continuous hormone therapy appropriate for the experienced gender (unless medically contraindicated)

Revision History

04/01/2026revisedLatest

Added reference link to the Medical Benefit Drug Policy titled Gonadotropin Releasing Hormone Analogs; removed reference link to the Benefit Interpretation Policy titled Medications and Off-Label Drugs; removed application language indicating this policy applies to UnitedHealthcare West plans; removed language pertaining to certain RCW sections.

revisedLatest

Revised language to state prior authorization must be done by UnitedHealthcare or delegated providers; clarified prior authorization process and organized criteria language for hormonal and surgical treatments.

Policy Summary

PayerUnitedHealthcare

PolicyGender Dysphoria Gender Identity Disorder Treatment Wa

Policy CodePolicy BIP197.N

Change TypeRevisions to prior auth, criteria, and Not Covered list

Effective DateApr 1, 2026

Next Review Date

Key ActionPrior authorization of medically necessary services must be done by UnitedHealthcare or delegated providers as determined by UnitedHealthcare.

SourceLink

On This Page

Mental health and physical conditions that could negatively impact the outcome of treatment have been assessed, with risks and benefits discussed

Understands the effect of gender-affirming hormone treatment on reproduction and they have explored reproductive options

Criteria for Adults - Surgical treatment

Surgical treatment for Gender Dysphoria may be indicated when ALL of the following are met; additional procedure-specific documentation requirements apply:

ALL of the following

Persistent, well-documented Gender Dysphoria
Capacity to make a fully informed decision and to consent for treatment
Must be at least 18 years of age
Favorable psychosocial-behavioral evaluation including screening and identification of risk factors or potential postoperative challenges
Procedure-specific additional requirements (examples listed separately)
- Breast surgery (mastectomy, breast reduction, or breast augmentation): Written clinical assessment from at least one Qualified Healthcare Professional experienced in treating Gender Dysphoria
- Thyroid cartilage reduction and/or voice modification surgery: Written clinical assessment from at least one Qualified Healthcare Professional experienced in treating Gender Dysphoria
- Genital surgery: Written clinical assessments from at least two Qualified Healthcare Professionals experienced in treating Gender Dysphoria who have independently assessed the individual

Procedure-specific documentation / additional criteria

When required by procedure, the assessment must document the following:

ALL of the following

Breast augmentation specific
- For breast augmentation, continued Gender Dysphoria following the completion of 12 months of continuous hormone therapy prior to the breast procedure is required.12 months continuous hormone therapy prior to procedure
Voice surgery specific
- Completion of 6 months of continuous hormone therapy prior to surgery is required for voice masculinization.6 months continuous hormone therapy prior to surgery
- For voice modification surgery, documentation of presurgical voice lessons and/or therapy.
Genital surgery specific
- Complete at least 12 months of successful continuous full-time real-life involvement in the identified gender.12 months continuous full-time real-life involvement
- Complete 12 months of continuous hormone therapy appropriate for the experienced gender (unless medically contraindicated or not indicated for gender).12 months continuous hormone therapy (unless contraindicated)
- Treatment plan that includes ongoing follow-up and care by a Qualified Healthcare Professional experienced in treating Gender Dysphoria.

Criteria for Adolescents (surgical)

In addition to the adult criteria, for surgical treatment in adolescents (under 18) ALL of the following (from a multidisciplinary team assessment) are required:

ALL of the following

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

Breast surgery (mastectomy, breast reduction, breast augmentation): written assessment from ≥1 QHP experienced in Gender Dysphoria care
Thyroid cartilage reduction / voice modification: written assessment from ≥1 QHP experienced in Gender Dysphoria care
Genital surgery: written assessments from ≥2 QHPs experienced in Gender Dysphoria care, independently performed

Documentation Required

Informed Consent & Reproductive Counseling

Documentation of informed consent and reproductive counseling is required. The record must show the individual has the capacity to consent for the specific procedure or treatment, that risks and benefits were discussed, and that reproductive implications were reviewed. The discussion should include fertility preservation options when relevant and evidence that the individual has explored reproductive options.

Documented capacity to provide informed consent for the specific gender-affirming treatment
Discussion of risks, benefits, and expected outcomes documented in the clinical record
Discussion of effect on reproduction and whether fertility preservation was offered or considered

Documentation Required

Real-Life Experience & Hormone Therapy Documentation

Documentation of real-life experience and hormone therapy is required where specified. Required durations include continuous real-life experience and continuous hormone therapy prior to certain surgeries; exact threshold durations are referenced in the policy and must be met and documented in the clinical record.

Genital surgery: documentation of ≥12 months of successful continuous full-time real-life involvement in the identified gender (unless otherwise noted) — see policy thresholds for exact values
Genital surgery: documentation of ≥12 months of continuous hormone therapy appropriate for the experienced gender (unless medically contraindicated or not indicated) — see policy thresholds for exact values
Breast augmentation: documentation of continued Gender Dysphoria following completion of 12 months of continuous hormone therapy prior to the procedure
Voice masculinization: documentation of completion of 6 months of continuous hormone therapy prior to surgery and presurgical voice lessons/therapy where required

Revised Not Covered list to remove multiple prior exclusions (including several pediatric and drug exclusions) and specified that treatment received outside the United States is not covered.