Obtain prior authorization where required

Surgical gender‑affirming procedures listed in the policy are medically necessary when the individual meets ALL listed criteria; prior authorization is expected where contractual or state rules require it and documentation must demonstrate the listed eligibility criteria (persistent gender dysphoria, capacity for informed consent, age ≥18, favorable psychosocial evaluation, and procedure‑specific requirements).

• Documentation demonstrating the criteria must be submitted when prior authorization is required.

Submit specified CPT/ICD codes and watch NC Medicaid annotations

Use the CPT and ICD‑10 codes enumerated in the policy for prior‑authorization and billing; note that several CPT codes are annotated with an asterisk in the policy and may have state‑specific coverage implications.

• Policy lists multiple procedure CPT codes (see Applicable CPT sections) and ICD‑10 codes (F64.x, Z87.890).
• Codes marked with an asterisk may not be on the NC Medicaid Fee Schedule and could affect coverage or prior authorization outcomes.

Confirm age ≥18 and documented multidisciplinary agreement

Delay genital gender‑affirming surgeries until the individual is at least 18 years old and ensure both a mental health practitioner and the clinician responsible for endocrine transition agree surgery is medically necessary and would benefit the patient before referral.

• Endocrine Society suggests waiting until age ≥18 for genital surgeries.
• Obtain documented concurrence from MHP and endocrine clinician that surgery is indicated.

Document full policy criteria and note NC code exceptions

When requesting authorization for surgical procedures, provide documentation that the individual meets ALL listed policy criteria; for North Carolina members, be aware CPT codes 58570–58573 are noted as not on the NC Medicaid Fee Schedule and therefore may not be covered.

• Include evidence of persistent Gender Dysphoria, informed consent capacity, age ≥18, psychosocial evaluation, and any procedure‑specific prerequisites.
• Highlight potential noncoverage for CPT 58570–58573 for NC Medicaid members.

Respond to authorization requests with complete records

Ensure any additional provider actions or clarifications requested during authorization are addressed promptly with supporting medical record documentation as the policy permits medical‑record review to determine medical necessity.

• Medical records may be requested to assess whether the member meets clinical criteria; make documentation available upon request.

Include documentation of voice therapy when applicable

Document completion of presurgical voice lessons and/or voice therapy when seeking authorization for voice modification procedures; voice therapy is commonly used prior to or alongside surgical voice procedures per evidence reviews and guidance.

• Hayes and guideline reviews describe voice therapy as an adjunct or prerequisite; include records of voice therapy or lessons in the submission.

Provide ≥12 months hormone therapy documentation for genital surgery

For genital surgery requests, document at least 12 months of continuous hormone therapy appropriate for the experienced gender unless hormones are medically contraindicated or not desired; include hormone treatment records in the authorization packet.

• Endocrine Society recommends completion of ≥1 year of consistent hormone therapy prior to genital surgery unless contraindicated.
• Provide clear records of hormone therapy duration and adherence when submitting for authorization.

Provide timely supplemental records on request

If the reviewer requests additional high‑importance information during prior authorization, supply timely, legible medical record documentation to avoid delayed or adverse determinations.

• Make records available promptly when requested; incomplete documentation can delay determinations.

Keep complete, legible medical record documentation

Maintain legible medical records that fully support medical necessity, including relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures; records must be available upon request for review.

• Documentation should be legible, kept in the patient's record, and made available upon request.
• Include history, exam findings, diagnostic test results, and treatment course to support the request.

Document a clear diagnosis of gender dysphoria

Accurately establish and document the diagnosis of gender incongruence or gender dysphoria in the record, since a clearly defined diagnosis underlies clinical decision‑making and is required to support interventions.

• Include diagnostic criteria and assessment that support the diagnosis used for the request.

Include multidisciplinary assessments and treatment course for genital surgery

For genital procedures, document multidisciplinary agreement per Endocrine Society guidance: written assessments from at least two Qualified Healthcare Professionals who have independently evaluated the individual and confirmation that criteria (real‑life experience, hormone therapy, treatment plan) are met.

• Provide two independent written clinical assessments for genital surgery.
• Include documentation of 12 months real‑life experience, 12 months hormone therapy (unless contraindicated), and a follow‑up treatment plan.

Prepare records that fully support medical necessity

Ensure the patient's medical record contains documentation that fully supports medical necessity for requested services, including medical history, physical exam, and diagnostic results; this documentation may be requested for review during authorization.

• Records should be comprehensive and demonstrate how the patient meets the policy criteria.
• Be prepared to supply these documents when prior‑authorization reviewers request them.

Missing documentation may cause denial

Be aware that lack of medical record documentation supporting medical necessity may result in denial of requested services; ensure submissions include the required clinical evidence and assessments.

• Incomplete or missing documentation is a common reason for denial.
• Provide procedure‑specific prerequisites and clinician assessments to reduce risk of denial.

Codes marked '*' may be noncovered for NC Medicaid

Requests that use CPT codes marked with an asterisk in the policy may not be covered by North Carolina Medicaid because those codes are not on the NC Medicaid Fee Schedule; check state fee‑schedule applicability before submission.

• Codes 58570–58573 are specifically noted as not on the State of North Carolina Medicaid Fee Schedule and may not be covered.
• Review code annotations in the policy when preparing claims for NC Medicaid members.

Anticipate evidence‑based coverage review for some procedures

Recognize that evidence for many gender‑affirming procedures has limitations (lack of controlled studies, prospective data, and validated outcome measures); these evidence gaps may influence medical‑necessity review and coverage decisions.

• Policy and cited reviews note low‑quality or limited evidence for many procedures, which can affect coverage determinations.
• Be prepared to provide procedure‑specific rationale and outcome expectations when evidence is limited.

NC Medicaid risk: CPT 58570–58573 may be denied

Specifically for North Carolina Medicaid members, requests using CPT codes 58570, 58571, 58572, or 58573 may be denied because the policy notes these codes are not on the NC Medicaid Fee Schedule.

• Do not rely on coverage for these hysterectomy CPT codes for NC Medicaid without separate confirmation.
• Consider alternative applicable CPT codes listed in the policy when appropriate.