ModifiedUnitedHealthcarePolicy CS145PA.P

Gender Dysphoria Treatment (for Pennsylvania Only)

Policy governing medical necessity and coverage criteria for gender-affirming care (behavioral, hormonal, and surgical) for members in Pennsylvania; applies to UnitedHealthcare plans where the policy is in effect and references state requirements. Affects providers requesting authorization for gender dysphoria–related services for Pennsylvania members.

Policy Summary

PayerUnitedHealthcare

PolicyGender Dysphoria Treatment (for Pennsylvania Only)

Policy CodePolicy CS145PA.P

Change TypeMaterial additions and clarifications to documentation and governing requirements

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain and submit complete medical record documentation that fully supports medical necessity, including history, physical exam, and pertinent diagnostic test results, when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and applicable laws which may require coverage for a specific service.

Added requirements that medical records documentation may be required to assess whether the member meets clinical criteria and that documentation must fully support medical necessity.

Updated list of examples of non-covered treatments/services and removed reproductive services examples such as sperm preservation and cryopreservation.

Pennsylvania-onlyjurisdiction

WPATH v8references

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Coverage Criteria and Medical Necessity

Adult surgical medical necessity criteria

Surgical treatment for Gender Dysphoria in adults 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:

Adult surgical criteria: Gender incongruence is marked and sustained.

Adult surgical criteria: Meets diagnostic criteria for gender incongruence.

Adult surgical criteria: Demonstrates capacity to consent for the specific gender-affirming surgical intervention.

Adult surgical criteria: Understands the effect of gender-affirming surgical intervention on reproduction and has explored reproductive options.

Adult surgical criteria: Other possible causes of apparent gender incongruence have been identified and excluded.

Adult surgical criteria: Mental health and physical conditions that could negatively impact the outcome of gender-affirming surgical intervention have been assessed, and risks and benefits have been discussed.

Adult surgical criteria: Stable on their gender-affirming hormonal treatment regimen (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result), unless hormone therapy is either not desired or is medically contraindicated.

Detransition/retransition surgical criteria

Additional criteria for individuals seeking detransition/retransition (in addition to the adult criteria above):

Detransition/retransition surgical criteria: Documentation of a comprehensive multidisciplinary assessment by health care professionals experienced in transgender health that includes exploration of concerns with previous physical changes and efforts to ensure similar concerns are not replicated by further physical changes.

Detransition/retransition surgical criteria: A recommended period of living in role before further physical changes are recommended.

Detransition/retransition surgical criteria: Evaluation of the etiology of regret, if applicable, as well as the temporal stability of the surgical request.

Adolescent surgical medical necessity criteria

Surgical treatment for Gender Dysphoria in adolescents may be indicated when ALL of the following are met, as documented by a multidisciplinary team, including both medical and mental health professionals:

Adolescent surgical criteria: Gender diversity/incongruence is marked and sustained over time.

Adolescent surgical criteria: Meets the diagnostic criteria of gender incongruence.

Adolescent surgical criteria: Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.

Adolescent surgical criteria: 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.

General coverage when benefits apply

General coverage stance when benefits apply:

Covered services when plan covers gender dysphoria treatment: If a plan covers treatment for Gender Dysphoria, coverage includes psychotherapy, hormone therapy, puberty suppressing medications, laboratory testing to monitor the safety of hormone therapy, and certain surgical treatments listed in the Coverage Rationale section; specific plan, federal, or state contractual details may vary.

Covered services with documentation

Covered when ALL of the following are met:

Plan and governing requirements: The member's benefit plan and applicable federal, state, or contractual requirements include coverage for the requested gender dysphoria treatment.

Determination defaults to governing requirements in case of conflict.

Documentation supports medical necessity: The patient's medical record contains documentation that fully supports medical necessity for the requested service, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; documentation must be legible, maintained in the patient's medical record, and made available upon request.

Medical records may be requested during reviews.

Certain treatments and services are not covered. Examples include but are not limited to: treatments and procedures that are specifically excluded or otherwise do not meet the requirements of a Covered Health Care Service under federal, state, or contractual requirements and treatment received outside of the United States. Cosmetic procedures are also excluded per the referenced Cosmetic and Reconstructive Procedures policy.

Exclusions may also reflect applicable governing requirements; when plan benefits do not include a requested gender dysphoria service per the member's benefit plan or controlling federal, state, or contractual rules, that service is excluded. Cosmetic procedures remain excluded and examples of non-covered services were updated in the Benefit Considerations section of the policy.

Coverage does not apply to members who do not meet the indications listed in the Coverage Rationale section above.

Services that fail to meet the documented clinical indications in the Coverage Rationale are not covered; claims for such services may be denied under the policy exclusions.

Applicable Procedure and Diagnosis Codes

Applicable procedure and diagnosis codes (partial list shown)mixed

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
14000	Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
14001	Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
14041	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
15734	Muscle, myocutaneous, or fasciocutaneous flap; trunk
15738	Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
15750	Flap; neurovascular pedicle

1–10 of 140

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Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required when plan benefits include gender dysphoria treatments. Medical records must demonstrate the member meets the clinical criteria described in the Coverage Rationale (including applicable age-specific criteria) and any applicable federal, state, or contractual requirements.

Prior authorization may be required per the governing federal, state, or contractual requirements.
Medical records must be submitted and must fully support medical necessity for the requested services.

Documentation Required

Required Medical Record Documentation

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. This documentation should be legible, maintained in the patient's medical record, and made available upon request.

Include relevant medical history and physical examination findings.

Background and Scope

Gender dysphoria is a marked incongruence between an individual’s experienced or expressed gender and their assigned gender that is associated with clinically significant distress or impairment. Gender-affirming care encompasses a range of interventions including psychotherapy, hormone therapy, puberty suppression medications, laboratory monitoring, and certain surgical procedures (for adolescents and adults) such as chest, genital, and facial surgeries. Surgical interventions have specific criteria addressing diagnostic confirmation, informed consent/assent, assessment of mental and physical conditions, reproductive counseling, and hormone therapy history where applicable.

Key Definitions

Gender Dysphoria (Adolescents and Adults) — DSM-5-TR criteria

Definition (DSM-5-TR)A marked incongruence between experienced/expressed gender and assigned gender, of at least 6 months' duration, manifested by at least two specific symptoms (e.g., incongruence with primary/secondary sex characteristics; strong desire to be rid of primary/secondary sex characteristics; strong desire for characteristics of the other gender; strong desire to be treated as or to be the other gender; strong conviction of having typical feelings/reactions of the other gender).

Duration requirementAt least 6 months' duration is required for the diagnosis.

Symptom thresholdAt least two of the listed symptom criteria must be present for adolescents and adults.

Associated impairmentThe condition must be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Examples of symptom manifestationsExamples include marked incongruence with primary/secondary sex characteristics, strong desire to be rid of those characteristics, desire to be of the other gender, desire to be treated as the other gender, or conviction of having the other gender's typical feelings and reactions.

Policy Summary

PayerUnitedHealthcare

PolicyGender Dysphoria Treatment (for Pennsylvania Only)

Policy CodePolicy CS145PA.P

Change TypeMaterial additions and clarifications to documentation and governing requirements

Effective DateMay 1, 2026

Next Review DateN/A

SourceLink

On This Page

Denial Risk

Denial Risk and Triggers

Coverage may be denied when documentation is insufficient or when services do not meet the Coverage Rationale/indications. Denials can also result when services are specifically excluded by the federal, state, or contractual requirements governing the member's plan.

Lack of medical record documentation fully supporting medical necessity.
Requested services that do not meet the Coverage Rationale clinical indications.
Services that are specifically excluded under the member's federal, state, or contractual benefits.
Treatment received outside the United States (when excluded by the plan).
Cosmetic procedures excluded per applicable policy guidance.

Gender Dysphoria (Children) — DSM-5-TR criteria

Definition (DSM-5-TR)A marked incongruence between experienced/expressed gender and assigned gender, of at least 6 months' duration, manifested by at least six specific symptoms (one of which must be criterion A1).

Duration requirementAt least 6 months' duration is required for the diagnosis in children.

Symptom threshold and requirementAt least six of the listed symptom criteria must be present, and one must be the criterion A1 (a strong desire to be of the other gender or insistence that one is the other gender).

Examples of child-specific symptomsChild criteria include preferences for cross-gender clothing or roles, strong preference for toys/activities/playmates of the other gender, strong dislike of one's sexual anatomy, and a strong desire for sex characteristics that match experienced gender.

Associated impairmentThe condition must be associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Gender dysphoria treatment — scope of care

Scope of care includedWhen a plan covers treatment for Gender Dysphoria, coverage may include psychotherapy, hormone therapy, puberty-suppressing medications, laboratory testing to monitor hormone therapy safety, and certain surgical treatments listed in the Coverage Rationale.

Monitoring and laboratory testingLaboratory testing to monitor the safety of hormone therapy is included when hormone therapy is covered.

Puberty suppressionPuberty suppressing medications are included when the plan covers gender dysphoria treatment.

Surgical treatmentsCertain surgical procedures are referenced as covered in the Coverage Rationale section when the plan and governing requirements include such coverage; specific plans may not cover all listed surgical treatments.

Clinical standards referencedClinical standards (e.g., WPATH Standards of Care and DSM-5-TR) are referenced for guidance on treatment approaches and eligibility.