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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 2

    CHAPTER 519.24 Gender Affirmation Surgery

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    Defines West Virginia Medicaid coverage, medical necessity criteria, prior authorization, and documentation requirements for gender affirmation surgical procedures for members with Gender Dysphoria age 21 and older.

    Policy Summary
    PayerWest Virginia Bureau for Medical Services (Department of Human Services)
    PolicyCHAPTER 519.24 Gender Affirmation Surgery
    Policy CodePolicy Policy 2
    Change TypeNo material change
    Effective DateSep 1, 2022
    Last ReviewSep 1, 2022
    Next Review Date
    Key ActionObtain prior authorization for all gender affirmation surgeries; provide required documentation including two independent mental health evaluations and the surgeon's letter confirming candidate criteria.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    21+minimum member age
    2required MH evaluations
    12 moliving/hormone duration
    Prior Authorization

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    authorization
    Extensiveextensive exclusions

    Coverage Criteria for Gender-Affirming Surgery

    General candidate criteria (must meet ALL)

    Covered when ALL of the following are met

    Age: Member must be 21 years or older prior to being considered for this procedure.>=21 years
    Mental health evaluations: Two separate assessments by qualified, unaffiliated mental health professionals each resulting in a DSM-V diagnosis of Gender Dysphoria.2 independent evaluations

    Letters must document diagnosis, participation in treatment plan, co-morbid conditions, counseling of treatment options, and readiness for surgery.

    Psychotherapy requirement: Psychotherapy for a minimum of 8 visits in the 12 months preceding surgery.>=8 visits in 12 months

    Face-to-face, in-person assessment required.

    Living in affirmed gender: Completion of at least 12 continuous months of living as affirmed gender (MTF or FTM) in all aspects of daily living documented in medical/psychological records.12 months continuous

    Real-life experience trial must be documented.

    Hormone therapy: Documentation of 12 months continuous hormone therapy as appropriate to the member's gender goals, unless medically contraindicated with documentation explaining why hormones are not clinically indicated.12 months or documented contraindication

    Follow-up every three months during the first year of hormone therapy to monitor levels.

    Surgeon documentation: Treating surgeon's letter confirming the member meets candidate criteria, that the member is likely to benefit, and that risks, required hospitalization length, and post-surgical rehabilitation have been discussed with the member and mental health provider.letter from treating surgeon

    Surgeon must have personally communicated with treating mental health provider and the member.

    Procedures considered medically necessary (when criteria and prior auth met)

    The following surgeries may be considered medically necessary when ALL candidate criteria are met and prior authorization is obtained:

    Male-to-Female (MTF) procedures: Orchiectomy; Penectomy; Vaginoplasty; Colovaginoplasty; Clitoroplasty; Labiaplasty; Augmentation Mammoplasty; Perineoplasty.
    Female-to-Male (FTM) procedures: Breast reduction (mastectomy/reduction mammoplasty); Hysterectomy; Salpingo-oophorectomy; Colpectomy/Vaginectomy; Trachelectomy (Cervicectomy); Vulvectomy; Metoidioplasty; Phalloplasty; Urethroplasty; Scrotoplasty; Testicular prosthesis implantation.

    West Virginia Medicaid explicitly lists several service categories that are not covered under this policy. Reversal of previously approved gender affirmation surgeries is not covered. Cryopreservation, storage, or thawing of reproductive tissue and surrogate parenting are also excluded from coverage. Requests for these services will be denied and are not eligible for a DHHR Fair Hearing or Desk/Document review.

    Services that primarily alter appearance but are not medically necessary to treat the member's underlying Gender Dysphoria are excluded as cosmetic. The policy provides an explicit, non‑exhaustive list of non‑covered cosmetic procedures including, but not limited to: abdominoplasty, blepharoplasty, brow lift, calf implants, cheek/malar implants, chemical peel, chin/nose implants or prosthesis, collagen injections, dermabrasion, hair transplantation, lip reduction, liposuction, mastopexy, neck tightening, pectoral implants for chest masculinization, removal of redundant skin, voice modifications (e.g., laryngoplasty, glottoplasty, shortening of the vocal cords), and gluteal augmentation. Requests for these cosmetic procedures will be denied.

    Procedure and Billing Codes

    Procedures listed as covered when criteria met (MTF)mixed
    OrchiectomyOrchiectomy
    PenectomyPenectomy
    VaginoplastyVaginoplasty
    ColovaginoplastyColovaginoplasty
    ClitoroplastyClitoroplasty
    LabiaplastyLabiaplasty
    Augmentation MammoplastyAugmentation Mammoplasty
    PerineoplastyPerineoplasty
    Procedures listed as covered when criteria met (FTM)mixed
    Breast reduction (mastectomy/reduction mammoplasty)Breast reduction (e.g., mastectomy, reduction mammoplasty)
    HysterectomyHysterectomy
    Salpingo-oophorectomySalpingo-oophorectomy
    Colpectomy/VaginectomyColpectomy/Vaginectomy
    Trachelectomy (Cervicectomy)Trachelectomy (Cervicectomy)
    VulvectomyVulvectomy
    MetoidioplastyMetoidioplasty
    PhalloplastyPhalloplasty
    UrethroplastyUrethroplasty
    ScrotoplastyScrotoplasty
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    Provider Requirements and Authorization

    Prior Authorization

    Prior authorization required for all gender affirmation surgeries

    Prior Authorization must be obtained for all gender affirmation surgeries; requests will be reviewed by the contracted utilization organization prior to services being performed.

    Step Therapy

    12‑month real‑life and hormone therapy trial required

    Members must complete at least 12 continuous months of living in the affirmed gender and documentation of 12 months continuous hormone therapy as appropriate to the member's gender goals (unless medically contraindicated with documented rationale) prior to surgical treatment.

    • Documentation of follow-up every three months during the first year of hormone therapy to monitor hormone levels.
    • If hormones are contraindicated, the provider must document why hormone therapy is not clinically indicated.

    Background and Scope

    Gender Dysphoria is defined per DSM‑V as a condition in which a person experiences clinically significant distress due to an incongruence between their assigned sex at birth and their gender identity. Treatment commonly combines medical and psychological interventions, and formal evaluations are required prior to surgical interventions to establish medical necessity and readiness.

    Definitions

    inv-11: Gender Affirmation Surgery — definition and scope
    TermGender Affirmation Surgery
    DefinitionThe surgical procedures by which the physical appearance and function of a person's primary and/or secondary sex characteristics are modified to establish greater congruence with their gender identity.
    ScopeIncludes procedures that alter primary and/or secondary sex characteristics to align physical appearance and function with gender identity.
    inv-12: Gender Dysphoria — definition per document
    TermGender Dysphoria
    DefinitionA distressed state arising from conflict between a person's gender identity and the sex the person has or was identified as having at birth in accordance with the definition and diagnostic criteria established by the DSM-V.
    Policy Summary
    PayerWest Virginia Bureau for Medical Services (Department of Human Services)
    PolicyCHAPTER 519.24 Gender Affirmation Surgery
    Policy CodePolicy Policy 2
    Change TypeNo material change
    Effective DateSep 1, 2022
    Last ReviewSep 1, 2022
    Next Review Date
    Key ActionObtain prior authorization for all gender affirmation surgeries; provide required documentation including two independent mental health evaluations and the surgeon's letter confirming candidate criteria.
    SourceLink
    On This Page
    Coverage Criteria for Gender-Affirming SurgeryProcedure and Billing CodesProvider Requirements and AuthorizationBackground and ScopeDefinitions
    Documentation Required

    Required clinical documentation and qualifying letters

    Provide written clinical evaluations and letters documenting psychological assessment, medical necessity, treatment history, and surgeon confirmation per policy requirements.

    • Two separate assessments by qualified, unaffiliated mental health professionals, each resulting in a DSM‑V diagnosis of Gender Dysphoria; letters must document diagnosis, treatment participation, comorbid conditions, counseling, and psychotherapy (minimum 8 visits in the prior 12 months) and affirm face‑to‑face assessment.
    • One letter must be from a licensed behavioral health professional with appropriate credentials (e.g., Ph.D., M.D., LCSW, Ed.D., DSW, Psy.D., psychiatric nurse practitioner under supervision) or equivalent.
    • One letter must be from the candidate's established physician or behavioral health provider documenting duration of relationship, eligibility criteria met, rationale for hormone therapy/surgery, extent of psychotherapy during the 12‑month real‑life trial, and corroborating progress.
    • A treating surgeon's letter confirming candidate criteria are met, likelihood of benefit, communication with the treating mental health provider, and that required hospitalization length, possible complications, and post‑surgical rehabilitation were discussed.
    Denial Risk

    Non‑covered services will be denied (cosmetic, cryopreservation, surrogate parenting, reversal)

    Requests for services explicitly listed as non‑covered will be denied; these include reversal of approved surgeries, cryopreservation/storage/thawing of reproductive tissue, surrogate parenting, and cosmetic procedures that change appearance but are not medically necessary to treat gender dysphoria.

    • Examples of cosmetic procedures not covered (non‑inclusive): abdominoplasty, blepharoplasty, rhinoplasty/implants, liposuction, mastopexy, pectoral implants for masculinization, voice modifications (laryngoplasty/glottoplasty), gluteal augmentation, removal of redundant skin.
    • Non‑covered services are not eligible for a DHHR Fair Hearing or a Desk/Document review.
    Related conceptGender Identity: a person's internal sense of being male, female, some combination, or neither.