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    v1.0.28
    OpenPayerPolicy UpdatesGender-Affirming CareWest Virginia Medicaid gender-affirming surgery Co…
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    CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy N/A

    Comments for Chapter: 519.24 Gender Affirmation Surgery

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    Public comments and agency responses regarding Chapter 519.24 on coverage of gender-affirming surgery for West Virginia Medicaid members; clarifies surgical coverage scope and related questions such as hormone therapy and provider qualifications.

    Policy Summary
    PayerWest Virginia Bureau for Medical Services (Department of Human Services)
    PolicyComments for Chapter: 519.24 Gender Affirmation Surgery
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateSep 1, 2022
    Next Review DateN/A
    Key ActionDocument diagnosis of gender dysphoria and prior behavioral health and hormone therapies when submitting requests for surgical authorization.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    14public comments referenced
    9/1/2022policy effective
    Hormone therapy coveredpharmacy benefit
    Under 21

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    minors excluded

    Coverage Criteria for Gender-Affirming Surgery

    Surgical coverage with prior therapies

    Covered when ALL of the following are met

    Primary coverage conditions: 1) Diagnosis of gender dysphoria (behavioral health diagnosis as defined in the DSM-5-TR).

    Document diagnosis in the medical record per standards of practice (e.g., WPATH).

    Prior behavioral health therapy: 2) Behavioral health therapies have been provided prior to surgery and have not produced adequate or acceptable relief of symptoms.

    Evidence may include progress notes, treatment summaries, or letters from licensed behavioral health providers as described in the policy.

    Prior hormone therapy when appropriate: 3) Hormone therapy has been tried where clinically appropriate and provided for a prior period (documented), unless contraindicated or clinically inappropriate.

    Hormone therapy coverage is administered under the pharmacy benefit and documented use should be included in prior therapy documentation.

    Medical necessity per standards: 4) Surgery is determined to be medically necessary according to accepted clinical standards of practice (for example, WPATH/NIH) and clinical judgment.

    Procedures that do not meet standards of care or lack required documentation may be considered not medically necessary.

    Members under the age of 21 are not included for surgical services under this policy. The policy notes that many gender-affirming surgical procedures are irreversible (for example, hysterectomy), and that the surgical chapter is specific to procedures rather than serving as a comprehensive guide to all gender dysphoria treatments.

    Surgical interventions must align with recognized standards of care and be supported by appropriate prior therapies and documentation. Procedures that do not meet clinical standards (for example, those not defined as medically necessary by established guidance such as WPATH/NIH) or that lack documented trials of behavioral health and, where appropriate, hormone therapy may be considered not medically necessary and subject to denial.

    Provider Requirements, Authorization, and Documentation

    Prior Authorization

    Surgery prior authorization and pharmacy coverage

    Surgical procedures for gender affirmation are administered under Chapter 519.24 and are subject to the policy’s medical necessity criteria and prior authorization requirements. Pharmacologic (hormone) therapy is covered separately under the pharmacy benefit and is not authorized within the surgical chapter.

    Step Therapy

    Required prior therapies before surgery

    Behavioral health therapies and hormone therapy are expected to be provided and documented prior to consideration of gender-affirming surgery; surgery is appropriate when these therapies have been tried and provide no or unacceptable relief of symptoms.

    Key Definitions

    Medically Necessary Services
    DefinitionServices and supplies that are appropriate and necessary for the symptoms, diagnosis, or treatment of an illness; provided within standards of good practice (e.g., WPATH/NIH), not for convenience, and delivered at the appropriate level of care in the most efficient, cost‑effective manner.
    ScopeIncludes interventions (behavioral health, pharmacologic, surgical) when indicated by clinical standards and individual medical necessity assessments.
    Documentation requirementMust document diagnosis of gender dysphoria and prior relevant therapies (behavioral health and, where appropriate, hormone therapy) demonstrating inadequate symptom relief before surgery is considered.
    Benefit separationHormone therapy is covered under the pharmacy benefit and is addressed separately from the surgical chapter.
    Application of standardsDeterminations of medical necessity are made according to accepted medical standards of practice, including WPATH and NIH guidance.

    Background and Scope

    Gender dysphoria can be managed through a range of treatments including behavioral health therapies, hormone therapy, and surgical interventions. The policy references clinical standards (for example, WPATH and NIH) and notes supporting research and legal context cited in public comments. It also clarifies that the surgical policy focuses on procedures, that hormone therapy coverage is addressed separately (pharmacy benefit), and that some surgeries are not reversible.

    Revision History

    2022-09-01policy_effective

    Chapter 519.24 Gender Affirmation Surgery policy became effective; establishes coverage criteria and references that hormone therapy is covered under the pharmacy benefit separate from the surgical chapter.

    2022-09-22public_comment_response

    Response to public comment confirming that hormone therapy after surgery is covered under the pharmacy benefit and not within Chapter 519.24 (surgery chapter).

    2022-09-25public_comment_response
    Policy Summary
    PayerWest Virginia Bureau for Medical Services (Department of Human Services)
    PolicyComments for Chapter: 519.24 Gender Affirmation Surgery
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateSep 1, 2022
    Next Review DateN/A
    Key ActionDocument diagnosis of gender dysphoria and prior behavioral health and hormone therapies when submitting requests for surgical authorization.
    SourceLink
    On This Page
    Coverage Criteria for Gender-Affirming SurgeryProvider Requirements, Authorization, and DocumentationKey DefinitionsBackground and ScopeRevision History
    Documentation Required

    Required documentation to support authorization

    Providers must document a diagnosis of gender dysphoria and evidence that behavioral health therapies and hormone therapy were tried without adequate symptom relief; letters or assessments from licensed clinicians (e.g., MD/DO, PhD, EdD, PA, LCSW) are referenced as acceptable supporting documentation.

    Denial Risk

    Potential basis for denial

    A prior authorization or coverage determination may be denied if the member lacks a documented diagnosis of gender dysphoria, or if behavioral health and/or hormone therapies were not tried or not documented to have failed or provided unacceptable relief.

    • Denial risk when required prior therapies are not documented as attempted.
    • Denial risk when documentation (diagnosis or provider assessments/letters) is missing or insufficient.
    • Denial risk when procedures do not meet applicable standards of care.
    Gender Affirmation Surgery
    DefinitionSurgical procedures defined by medical standards of practice (e.g., WPATH, NIH) as treatments for gender dysphoria, performed to treat clinically significant gender dysphoria when other therapies have not provided adequate relief.
    ExamplesProcedures may include surgeries commonly performed by specialists in the relevant body area (e.g., hysterectomy by gynecologic surgeons); specific procedures vary by clinical need.
    PrerequisitesSurgery is considered appropriate after behavioral health therapies and hormone therapy (when appropriate) have been provided and failed to produce acceptable symptom relief.
    Provider qualificationsSurgeons are those licensed and vetted through Medicaid and applicable state licensing bodies; some procedures may already be performed in WV by surgeons who specialize in the relevant body area.
    Age considerationsMembers under age 21 are not included for these surgical services under this policy.
    Latest

    Responses provided clarifying definitions of medically necessary services, the process for submitting public comments, and that members under age 21 are not included for surgical services under this policy at this time.