Prior authorization required for mastectomy

Prior authorization is required for gender-affirming mastectomy and must include documentation that all general criteria in Policy Statement I are met and that the referring qualified professional documented assessment of breast cancer risk prior to mastectomy.

• Prior authorization must demonstrate all general eligibility criteria are satisfied.
• Referring qualified professional's letter must document breast cancer risk assessment prior to mastectomy.

Prior authorization submission requirements (qualified professional letters)

Submit prior authorization with the qualified professional's referral letter documenting required elements such as DSM-5-TR gender dysphoria diagnosis of ≥6 months, documentation of completion of six months continuous hormone therapy (or medical contraindication) when applicable, and parental/guardian consent or assent documentation for minors when applicable.

• Referral letter must document DSM-5-TR gender dysphoria and duration ≥6 months.
• When required by procedure, letter must document six months continuous hormone therapy or a contraindication.
• For minors, include documentation of informed assent or legally responsible party consent.

Medical director review required for voice/ancillary procedures

Services for voice modification and certain ancillary procedures require review/approval by a Health Plan Behavioral Health Medical Director; prior authorization must indicate the case will be reviewed by the Behavioral Health Medical Director.

• CPT 92507 (voice/communication therapy) and voice modification surgeries require Behavioral Health Medical Director review.
• Ancillary procedures undergo clinical documentation review by the Health Plan Behavioral Health Medical Director.

Clinical/medical director review required for revisions and out‑of‑network care

Revision surgeries and other complex requests will undergo clinical documentation review by a Health Plan Behavioral Health Medical Director; prior authorization must include clinical records sufficient for that review. Out‑of‑network, non‑urgent care also requires prior approval by the Behavioral Health Medical Director based on medical necessity.

• Provide clinical documentation detailing post‑operative clinically significant discomfort, distress, limitations, or marked functional deficit for revision requests.
• Out‑of‑network non‑urgent or non‑emergent care requires approval by a Health Plan Behavioral Health Medical Director for coverage.

Out‑of‑network non‑urgent care requires authorization

Non‑urgent or non‑emergent out‑of‑network care must be authorized by a Health Plan Behavioral Health Medical Director for the plan to cover the service.

• Obtain prior approval from the Health Plan Behavioral Health Medical Director when requesting coverage for out‑of‑network non‑urgent services.

Peer review and remote surgery prior authorization requirements

Refer cases that require clinical peer review to the Health Plan Behavioral Health Medical Director; when surgery is performed remotely, prior authorization must document local surgical/medical backup and postoperative care arrangements.

• Clinical peer review cases are conducted by the Health Plan Behavioral Health Medical Director.
• For remote surgeries, include documentation of responsible local medical/surgical providers and a detailed postoperative care plan.

Prior authorization advised for listed procedure codes

Obtain prior authorization for procedures billed with the listed CPT codes; the policy warns the code list may be incomplete and codes may not be covered in all circumstances, so providers should secure prior authorization when billing these codes.

• Codes listed in the policy may not be all‑inclusive; verify coverage via prior authorization.
• Prior authorization should be obtained when billing listed CPT codes for gender‑affirming procedures.

Prior authorization tied to product coverage

Prior authorization and coverage determinations are subject to the member's product benefits; confirm product coverage before submitting authorization because criteria apply only when the product covers the service.

• If a product does not cover a specific service, medical policy criteria do not apply and denial may be based on product exclusions.
• When the product covers the service, medical policy criteria and prior authorization requirements apply.

Voice/communication therapy reviewed separately (Policy VII)

Voice and communication therapy (CPT 92507) is reviewed under Policy Statement VII and is handled separately from the general criteria in this section; do not apply general surgical criteria to CPT 92507 authorization.

• CPT 92507 is subject to Policy Statement VII review.
• General criteria in Policy Statement I are not required for voice therapy referrals per the voice therapy note.

Step therapy: voice therapy trial required before voice surgery

A documented trial of voice therapy is required prior to approval of voice modification surgery; prior authorization for voice modification must include evidence of the trial and a documented post‑operative voice training plan.

• Qualified professional's letter must document completion of a voice therapy trial before voice modification surgery.
• Include a post‑operative treatment plan that incorporates voice training.

Conservative intervention requirement for some non‑staged ancillary procedures

For certain non‑staged ancillary procedures, prior authorization must include documentation that conservative medical or surgical interventions have failed or are contraindicated (e.g., diet/exercise prior to body contouring).

• Provide records showing conservative interventions were attempted and failed, or documentation of contraindication to conservative care.
• This requirement applies to non‑staged ancillary procedures when listed in the policy examples.

Conservative therapy requirement for non‑staged procedures

Non‑staged ancillary procedures require documentation that conservative medical or surgical interventions have failed or are contraindicated; include this information in prior authorization requests.

• Document failed conservative measures (e.g., diet/exercise) or provide contraindication evidence.
• Treating surgeon or qualified professional documentation should accompany the authorization.

Hormone therapy documentation for genital surgery

Genital surgeries generally require documentation of a period of consistent hormone therapy prior to approval—typically at least 6 months for adults—unless hormones are not desired or are medically contraindicated; include endocrine treatment documentation with prior authorization.

• Endocrine guidance recommends clinicians approve genital surgery after ≥1 year of consistent hormone treatment per Endocrine Society, and WPATH suggests consideration of ≥6 months tolerance for adults.
• If hormone therapy is not desired or is contraindicated, document that in the referral letter.

Required referral documentation: one qualified professional letter

One referral letter from a qualified professional must be included with prior authorization and must document a DSM-5-TR gender dysphoria diagnosis of at least 6 months, exclusion of other causes, assessment and control of comorbid conditions, and capacity to consent including risks/benefits and postoperative care.

• Referral letter must document diagnosis meeting DSM‑5‑TR criteria and duration ≥6 months.
• Include assessment that other causes of apparent gender dysphoria are excluded and relevant conditions are assessed and reasonably well‑controlled.
• Letter must document capacity to consent, discussion of risks/benefits, and postoperative care considerations.

Required clinical documentation elements for authorization

Required documentation must include the qualified professional's assessment of readiness, embodiment goals, emotional/cognitive maturity for minors (or parental/guardian consent), documentation of hormone therapy duration or contraindication when applicable, and voice therapy trial and post‑operative plan when relevant.

• Document readiness and embodiment goals and how they relate to the requested procedure.
• For minors, include emotional/cognitive maturity assessment or parental/guardian consent.
• When applicable, document six months continuous hormone therapy or a medical contraindication.
• For voice surgery, include evidence of voice therapy trial and a post‑op voice treatment plan.

One qualified professional referral letter and surgeon documentation for staged procedures

A single qualified professional referral letter must document the member's readiness for gender‑affirming care, including gender‑related experiences and how requested treatment fits the member's goals; when the requested ancillary procedure is a staged component of previously approved genital surgery, include documentation from the treating surgeon confirming staged relationship.

• One qualified professional letter documenting readiness and embodiment goals is required.
• Treating surgeon documentation attesting that an ancillary procedure is a staged component of previously approved genital surgery must be included for staged procedures.

Document readiness and embodiment goals

Documentation must describe the member's readiness and embodiment goals and explain how those goals relate to the requested gender‑affirming procedure; include this in the prior authorization package.

• Explain embodiment goals and the connection to the requested intervention.
• Include objective and narrative documentation to support readiness.

Documentation required for revision surgery prior authorization

For revision surgery prior authorization, include documentation of post‑operative clinically significant discomfort, distress, limitations, or marked functional deficit that interferes with activities of daily living to support medical necessity.

• Detail postoperative pain, functional impairment, distress, or limitations interfering with ADLs.
• Clinical documentation will be reviewed by the Health Plan Behavioral Health Medical Director.

Documentation required for reversal procedures

Clinical records documenting a serious medical condition are required when requesting reversal of prior gender‑affirming surgery; such requests will be reviewed by a Health Plan Behavioral Health Medical Director (with Physical Health Medical Director consultation as needed).

• Provide clinical documentation of the serious medical condition necessitating reversal.
• Requests without such documentation will be considered not medically necessary.

Qualified professional assessment and informed consent documentation

Qualified health care professional assessment must document informed consent addressing fertility impact, irreversibility, and SOC‑8 topics; include documentation of informed consent with the prior authorization submission.

• Document that the qualified professional discussed fertility preservation and irreversibility.
• Include consent documentation aligned with SOC‑8 topics.

Preoperative permanent hair removal documentation

Prior authorization must include documentation of preoperative permanent hair removal for any skin area that will contact urine or be moved into a partially closed cavity (e.g., neourethra, neovagina).

• Provide records showing permanent hair removal of donor sites that will contact urine or be relocated into partially closed cavities.
• This requirement applies to genital gender‑affirming surgeries.

Regulatory documentation requirement (NYS guidance)

New York State regulatory guidance requires the plan provide coverage for diagnosis and treatment of mental, nervous, or emotional disorders when the health plan contract includes inpatient hospital care and/or physician services; include regulatory documentation as applicable.

• If the product covers inpatient/physician services, coverage for relevant mental health diagnosis/treatment must be provided per NYS law.
• Reference applicable product contract when preparing authorization.

Applicability and product coverage note for authorization

If a member's product covers a service, medical policy criteria apply; if a product does not cover a service (including some Medicare products), the policy does not override product exclusions—verify product coverage and include applicability note in the authorization.

• Confirm whether the member's commercial, Medicare, or Medicaid product covers the requested service before submitting prior authorization.
• If the product does not cover the service, denial may be based on benefit exclusion rather than medical necessity criteria.

Denial trigger: missing general criteria

Failure to meet all general criteria for medical necessity (as listed) may result in denial; ensure the referral letter and supporting records address every general criterion before submitting authorization.

• Verify the referral letter documents DSM‑5‑TR diagnosis, duration, exclusion of other causes, assessment and control of comorbid conditions, capacity to consent, and postoperative care planning.
• Missing required general criteria is a trigger for denial.

Denial triggers: missing procedure‑specific documentation

Coverage may be denied if required qualified professional letters, hormone therapy duration (or documented contraindication), parental/guardian consent for minors, or required Behavioral Health Medical Director review for voice surgery are not documented in the authorization.

• Omit or incomplete documentation of required referral letters can trigger denial.
• Lack of documented hormone therapy duration or contraindication when required may lead to denial.
• For minors, absence of assent or parental/guardian consent documentation may trigger denial.
• Failure to obtain Behavioral Health Medical Director review for voice modification may trigger denial.

Denial risk for continuation of voice therapy at maintenance level

Continuation of voice therapy services may be denied if the treating speech‑language pathologist documents the member has reached a maintenance service level with no additional functional progress expected; include objective measures of progress in continued authorization requests.

• Document objective improvement to support ongoing voice therapy.
• If maintenance level is reached with no further functional gains, continuation may be denied.

Denial risk if reconstructive/medical appropriateness criteria not met

Surgeries or procedures that do not meet the policy's reconstructive/medical appropriateness criteria are considered not medically necessary and subject to denial; prior authorization must demonstrate how the request meets the reconstructive criteria.

• Show that the procedure is appropriate, required for direct care of gender dysphoria, consistent with accepted medical practice, not primarily for convenience, and supported by evidence.
• Lack of evidence that the procedure meets reconstructive criteria may lead to denial.

Denial risk for reversal procedures without documented serious medical condition

Requests to reverse prior gender‑affirming surgery will be considered not medically necessary unless clinical records document a serious medical condition necessitating reversal; include such clinical documentation for authorization and anticipate review by medical directors.

• Provide clear clinical records that a serious medical condition necessitates reversal.
• Absent such documentation, reversal procedures are generally considered not medically necessary.

Denial risk for out‑of‑network non‑urgent care without approval

Care provided by out‑of‑network providers for non‑urgent/non‑emergent services is not covered unless approved by a Health Plan Behavioral Health Medical Director based on medical necessity; obtain prior authorization for out‑of‑network services.

• Submit prior authorization and medical necessity justification for out‑of‑network non‑urgent care.
• Without Behavioral Health Medical Director approval, coverage will be denied.

Denial risk: inadequate postoperative care plan for remote surgeries

Lack of an adequate postoperative care plan — including documentation that for remote surgeries responsible local medical/surgical providers will manage post‑surgical care — may lead to denial; plan to include comprehensive postoperative care details in authorization.

• Postoperative care must include sufficient medical, nursing, and emotional supports.
• For remote surgeries, document responsible local providers; urgent/emergency care alone is insufficient.

Denial constraint: cannot deny solely for gender dysphoria (verify necessity/benefits)

Denial cannot be based solely on the fact that treatment is for gender dysphoria per NYS guidance, but the plan may deny services that are not otherwise medically necessary or are not covered under the member's contract; verify both medical necessity and product coverage.

• Do not assume coverage solely because treatment is for gender dysphoria; confirm medical necessity and product benefit.
• NYS guidance prohibits denial solely because treatment is for gender dysphoria.