ModifiedUnitedHealthcarePolicy MMP365.12

Gender Dysphoria and Gender Reassignment Surgery

Medical policy governing coverage, coding, and references for gender dysphoria and gender reassignment surgery for UnitedHealthcare members; includes procedure and diagnosis codes and Medicare policy references.

Policy Summary

PayerUnitedHealthcare

PolicyGender Dysphoria and Gender Reassignment Surgery

Policy CodePolicy MMP365.12

Change TypeRevised — archived prior version and updated LCD/CMS references

Effective Date11/01/2025

Next Review Date

Key ActionObtain and follow applicable LCD/LCA and member benefit prior authorization requirements before providing gender‑affirming procedures.

SourceLink

POLICY UPDATE CHANGES

Coverage Rationale and CMS Local Coverage Determinations (LCDs) and Articles were updated and prior policy references were archived.

100+procedure and diagnosis codes listed

12+ICD-10/PCS entries

11/01/2025effective

MultipleCMS/LCD references

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Coverage determination hierarchy

Coverage follows applicable Medicare NCDs, LCDs, LCAs, and where absent, UnitedHealthcare internal criteria developed from clinical evidence.

Medicare/UnitedHealthcare coverage hierarchy: When an applicable NCD or LCD exists, UnitedHealthcare follows the Medicare coverage guidance; if no NCD/LCD/LCA is found for a procedure, refer to the Coverage Rationale and UnitedHealthcare internal criteria cited in this policy.

After checking the Medicare Coverage Database, if no NCD/LCD/LCA is found, apply the Coverage Rationale and UnitedHealthcare internal criteria as documented in this policy (see CMS-related documents and Instructions for Use).

Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage is determined by the member-specific benefit plan document and applicable laws, and the inclusion of a code does not guarantee reimbursement or payment.

Services determined to be cosmetic or otherwise non-covered under Medicare guidance should be identified by consulting CMS manuals and policy references, including the CMS Benefit Policy Manual, Chapter 16 §120 (Cosmetic Surgery) and related CMS guidance on services not covered under Medicare.

Procedures classified as cosmetic under Medicare guidance are not covered by Medicare; providers should consult the applicable Medicare manuals and member benefit documents to determine coverage. Listing of a code in this policy is for reference only and does not by itself determine whether a procedure classified as cosmetic is covered for a given member.

Procedure, Diagnosis, and Reference Codes

Male to Female procedures (selected)CPT

19325	Breast augmentation with implant.
54125	Amputation of penis; complete.
54520	Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach.
54690	Laparoscopy, surgical; orchiectomy.
55866	Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed.
55970	Intersex surgery; male to female.
56800	Plastic repair of introitus.
56805	Clitoroplasty for intersex state.
57291	Construction of artificial vagina; without graft.
57292	Construction of artificial vagina; with graft.

1–10 of 14

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Female to Male procedures (selected)CPT

19303	Mastectomy, simple, complete.
53420	Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage.
53425	Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage.
53430	Urethroplasty, reconstruction of female urethra.
54660	Insertion of testicular prosthesis (separate procedure).
55175	Scrotoplasty; simple.
55180	Scrotoplasty; complicated.
55980	Intersex surgery; female to male.
56625	Vulvectomy simple; complete.
57106	Vaginectomy, partial removal of vaginal wall.

1–10 of 12

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Other ancillary and reconstructive CPT codes (selected)CPT

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.
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.
17380	Electrolysis epilation, each 30 minutes.
19316	Mastopexy.
19318	Breast reduction.
19350	Nipple/areola reconstruction.
30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip.

Additional CPT and ICD-10 codes (selected)mixed

54400	Insertion of penile prosthesis; non-inflatable (semi-rigid).
54401	Insertion of penile prosthesis; inflatable (self-contained).
54405	Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir.
F64.0	Transsexualism.
F64.1	Dual role transvestism.
F64.2	Gender identity disorder of childhood.
F64.8	Other gender identity disorders.
F64.9	Gender identity disorder, unspecified.
Z87.890	Personal history of sex reassignment.

ICD-10-PCS / Inpatient procedure codes (selected)ICD-10-PCS

0U5J0ZZ	Destruction of clitoris, open approach.
0UB24ZZ	Excision of bilateral ovaries, percutaneous endoscopic approach.
0UT90ZZ	Resection of uterus, open approach.
0W4M070	Creation of vagina in male perineum with autologous tissue substitute, open approach.
0W4N071	Creation of penis in female perineum with autologous tissue substitute, open approach.

Applicable ICD-10-PCS procedure codes (partial)ICD-10

0UT98ZZ	Resection of uterus, via natural or artificial opening endoscopic.
0UT9FZZ	Resection of uterus, via natural or artificial opening with percutaneous endoscopic assistance.
0UTC0ZZ	Resection of cervix, open approach.
0UTC4ZZ	Resection of cervix, percutaneous endoscopic approach.
0UTC7ZZ	Resection of cervix, via natural or artificial opening.
0UTC8ZZ	Resection of cervix, via natural or artificial opening endoscopic.
0UTG0ZZ	Resection of vagina, open approach.
0UTG4ZZ	Resection of vagina, percutaneous endoscopic approach.
0UTG7ZZ	Resection of vagina, via natural or artificial opening.
0UTG8ZZ	Resection of vagina, via natural or artificial opening endoscopic.

1–10 of 24

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Applicable ICD-10-PCS procedure codes (continued)ICD-10

0VTS4ZZ	Resection of penis, percutaneous endoscopic approach.
0VTSXZZ	Resection of penis, external approach.
0VUS07Z	Supplement penis with autologous tissue substitute, open approach.
0VUS0JZ	Supplement penis with synthetic substitute, open approach.
0VUS0KZ	Supplement penis with nonautologous tissue substitute, open approach.
0VUS47Z	Supplement penis with autologous tissue substitute, percutaneous endoscopic approach.
0VUS4JZ	Supplement penis with synthetic substitute, percutaneous endoscopic approach.
0VUS4KZ	Supplement penis with nonautologous tissue substitute, percutaneous endoscopic approach.
0VUSX7Z	Supplement penis with autologous tissue substitute, external approach.
0VUSXJZ	Supplement penis with synthetic substitute, external approach.

1–10 of 16

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Related CMS / Medicare references (NCDs, LCDs, manuals, transmittals)mixed

No codes listed

NCD reference — NCD 140.9 Gender Dysphoria and Gender Reassignment Surgery

NCD identifierNCD 140.9

TitleGender Dysphoria and Gender Reassignment Surgery

CMS conclusionCMS determined no national coverage determination is appropriate at this time for gender reassignment surgery; coverage determinations will continue to be made by local Medicare Administrative Contractors (MACs) on a case-by-case basis.

When to follow NCDWhen applicable, UnitedHealthcare follows Medicare NCDs; if absent, refer to MAC LCDs/LCAs or UnitedHealthcare internal criteria.

Prior Authorization, Documentation, and Claims Responsibilities

Prior Authorization

Potential Prior Authorization Required

Coverage determinations for services described in this policy may require prior authorization per the member's benefit plan and any applicable CMS Local Coverage Determinations (LCDs) or Local Coverage Articles (LCAs). Providers should verify prior authorization requirements before rendering services to avoid claim denials or delays.

Prior authorization requirements vary by member-specific benefit plan.
Prior authorization may also be required by applicable LCDs/LCAs.
Verify Part B vs Part D medication coverage rules where applicable.

Denial Risk

LCD Compliance

Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) that apply to the service must be followed. Noncompliance with applicable LCDs/LCAs may result in claim denials. Refer to the policy table for specific LCD/LCA references and, where no LCD/LCA exists, refer to the UnitedHealthcare Commercial Medical Policy titled Gender Dysphoria Treatment as applicable.

Compliance with applicable LCDs/LCAs is required where they exist.
When an LCD/LCA is not available for a state/territory, follow the referenced UnitedHealthcare Commercial Medical Policy.

Billing Rule

Claims Accuracy and Documentation

Providers are responsible for accurate claims submission using appropriate CPT, HCPCS, ICD-10, and other coding guidelines. Listing of a code in this policy is for reference only and does not guarantee coverage or payment. Retain and submit documentation that supports the medical necessity of billed services and follow member-specific benefit rules.

Use current CPT/CMS coding guidelines when submitting claims.
Inclusion of a code in this policy does not imply coverage or guarantee reimbursement.
Claims must reflect services actually rendered and meet member-specific benefit requirements.

Documentation Required

Provider Documentation and Plan-Specific Requirements

Retain complete clinical records and documentation to support coverage decisions and provide them upon request. This policy is intended as a reference to assist providers in determining applicable medical necessity, documentation, and Medicare coding/billing requirements; it does not replace the member specific benefit plan document, which governs coverage. For Medicare Advantage members, if a delegate manages utilization management and prior authorization, follow the delegate's requirements.

Keep documentation available to support medical necessity and coding decisions.
Provide documentation to UnitedHealthcare upon request to substantiate coverage.
Follow delegate prior authorization and documentation requirements when a delegate manages utilization for the member's plan.

Key Terms and Policy Definitions

Gender reassignment surgery — general definition

DefinitionA general term to describe a surgery or surgeries that affirm a person's gender identity.

Scope of proceduresMay encompass multiple surgical interventions intended to align physical characteristics with a person’s gender identity.

Coverage hierarchy noteCoverage follows applicable Medicare NCDs, LCDs, LCAs; where Medicare guidance is absent, UnitedHealthcare internal criteria apply.

Documentation implicationProviders should document procedures and diagnoses using listed codes; listing does not guarantee coverage and benefit coverage is member-specific.

CMS NCD 140.9 — national coverage determination status

CMS findingCMS conducted a National Coverage Analysis and determined that no national coverage determination is appropriate at this time for gender reassignment surgery.

Implication for coverage decisionsIn the absence of an NCD, coverage determinations will be made by local Medicare Administrative Contractors (MACs) on a case-by-case basis.

UnitedHealthcare practiceUnitedHealthcare follows Medicare coverage guidance found in statutes, regulations, NCDs, and LCDs; where no Medicare guidance exists, internal criteria are applied.

Gender reassignment surgical procedures — definition and regulatory note

DefinitionSurgical interventions intended to treat gender dysphoria; many are standard surgical procedures not subject to FDA device approval.

FDA noteFDA approval alone is not a basis for coverage; devices used in procedures may require FDA approval while the surgical procedures themselves often do not.

Coverage approachCoverage follows Medicare/NCD/LCD guidance where available; if none exists, UnitedHealthcare internal criteria apply.

Policy useThis policy and Medicare source materials are resources to support coverage decisions but are not replacements for primary Medicare source materials.

OpenPayer

Gender Dysphoria and Gender Reassignment Surgery

Coverage Determinations and Applicability

Procedure, Diagnosis, and Reference Codes

Prior Authorization, Documentation, and Claims Responsibilities

Clinical Context and Scope

Key Terms and Policy Definitions