ambetter of North Carolina Inc.

Clinical Policy: Gender-Affirming Procedures Reference Number: HIM.NC.CP.MP.95 Date of Last Revision: 09/25 Coding Implications Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description Services for gender affirmation most often include hormone treatment, counseling, psychotherapy, complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate, genital reconstruction, facial hair removal, and certain facial plastic reconstruction. Not every individual will require each intervention, so necessity needs to be considered on an individualized basis. The criteria in this policy outline the medical necessity criteria for gender-affirming medical and surgical treatment (GAMST) when such services are included under the member/enrollee’s benefit plan contract provisions.

*Note: For procedures related to fertility preservation please see policy CP.MP.130 Fertility Preservation.

Policy/Criteria I. It is the policy of Ambetter of North Carolina that gender-affirming surgeries are considered medically necessary for members/enrollees when diagnosed with gender dysphoria or gender incongruence per section A. and when meeting the eligibility criteria in section B.

Note: Intersex individuals are not subject to the criteria in this policy.

A. Gender Dysphoria or Gender Incongruence Criteria:

1. Marked and sustained incongruence between the member/enrollee’s experienced/expressed gender and assigned gender, as indicated by two or more of the following: a. Marked incongruence between the member/enrollee’s experienced/expressed gender and primary and/or secondary sex characteristics; b. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender; c. A strong desire for the primary and/or secondary sex characteristics of the other gender; d. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender); e. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender); f. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender); g. The condition is associated with impairment in social, occupational, or other important areas of functioning; B. Eligibility criteria, all of the following:
2. Member/enrollee must be ≥ 18 years of age;
3. Capacity to make a fully informed decision (including, but not limited to, awareness of the potential effects of treatment on fertility) and to consent for treatment;
4. If significant medical or mental health concerns are present, they are reasonably well controlled;
5. Other possible causes of apparent gender dysphoria, gender incongruence, or gender diversity have been identified and excluded;
6. Minimum of one written statement with signature recommending gender-affirming medical and surgical treatment (GAMST) from a health care provider competent to independently assess and diagnose gender incongruence;
7. Assessment for GAMST from a provider who meets both of the following: a. Has experience in or is qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity (e.g., mental health professional, general medical practitioner, nurse, or other qualified health care provider); b. Is licensed by their statutory body and hold, at a minimum, a master’s degree in a clinical field related to transgender health or equivalent further clinical training and be statutorily regulated;
8. The documented assessment for GAMST meets all of the following: a. Identifies any mental or physical health conditions that could negatively impact the outcome of GAMST, with risks and benefits discussed; b. Notes the member/enrollee’s capacity to understand the effect of GAMST on reproduction and includes a discussion of reproductive options with the member/enrollee prior to the initiation of GAMST;
9. Member/enrollee remains stable on their gender affirming hormonal treatment regime (which may include at least six months of hormone treatment or longer if required to achieve the desired surgical result unless hormone therapy is either not desired or is medically contraindicated).

C. Gender-affirming surgeries are considered medically necessary when meeting above criteria and additional criteria as listed below for specific procedures:

1. For members/enrollees ≥ 18 years of age, any of the following: a. Penectomy; b. Urethroplasty; c. Mammoplasty; d. Mastectomy, and the member/enrollee has been assessed for risk factors associated with breast cancer; e. Clitoroplasty; f. Vulvoplasty; g. Labiaplasty; h. Vaginectomy; i. Vulvectomy; j. Scrotoplasty; k. Testicular prosthesis; l. Breast augmentation, and the member/enrollee has been assessed for risk factors associated with breast cancer; m. Phalloplasty; n. Metoidioplasty; o. Vaginoplasty; p. Gonadectomy (i.e., hysterectomy, salpingo-oophorectomy, orchiectomy; at least six months of hormone therapy may be considered prior to procedure, as appropriate for the member/enrollee’s goals).

II. It is the policy of Ambetter of North Carolina that gender affirming facial procedures will be considered for medical necessity on a case-by-case basis when meeting the following: A. Criteria has been met in section I.A. and I.B.; B. Requested procedure intends to correct existing facial appearance that demonstrates significant variation from standard appearance for the experienced gender. Possible procedures include, but are not limited to, the following:

1. Blepharoplasty;
2. Face lift/mid-face lift/brow lift;
3. Facial implants and bone reconstruction;
4. Hair removal/electrolysis;
5. Drugs for hair loss or growth;
6. Hair transplantation or hairline advancement;
7. Prosthetic or filler substances to alter contour;
8. Rhinoplasty;
9. Thyroid chondroplasty;
10. Removal of redundant skin;
11. Upper lip shortening and lip augmentation;
12. Chondrolaryngoplasty;
13. Voice modification surgery, therapy, or lessons.

III.It is the policy of Ambetter of North Carolina that per General Assembly of North Carolina Session 2023 House Bill 808-G.S. 90-21.152 for members < 18 years of age, the following are considered medically necessary when one of the following criteria is met: A. Surgical gender transition procedures:

1. The course of treatment commenced prior to August 1, 2023, and was still active as of that date;
2. In the reasonable medical judgement of the medical professional, it is in the best interest of the minor for the course of treatment to be continued or completed;
3. The minor’s parents or guardians consent to the continuation or completion of treatment. B. Services to persons born with a medically verifiable disorder of sex development, including a person with external biological sex characteristics that are unresolvedly ambiguous, such as those born with 46 XX chromosomes with virilization, 46 XY chromosomes with under- virilization, or having both ovarian and testicular tissue; C. Services provided when a physician has otherwise diagnosed a disorder of sexual development that the physician has determined through genetic or biochemical testing that the person does not have normal sex chromosome structure, sex steroid hormone production, or sex steroid hormone action; D. The treatment of any infection, injury, disease, or disorder that has been caused by or exacerbated by the performance of gender transition procedures, whether or not the gender transition procedure was performed in accordance with State and federal law; E. Breast reduction procedures for a female member/enrollee causing a physical disorder; F. Any procedure undertaken because the individual suffers from a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the individual in imminent danger of death or impairment of major bodily function unless surgery is performed; G. Any surgery, including those listed per House Bill 808-G.S. 90-21.150 (Genital gender reassignment surgery and Non-genital gender reassignment surgery), which a treating physician certifies is medically necessary to treat a physiological condition.

IV.It is the policy of Ambetter of North Carolina that for members < 18 years of age, surgical gender transition procedures for any other reasons than those listed in Section III. are prohibited per House Bill 808-G.S. 90-21.151.

V. It is the policy of Ambetter of North Carolina that revision procedures for affirming gender are medically necessary when the revision is required to address complications of a prior gender affirming procedure (wound dehiscence, fistula, chronic pain directly related to the surgery, etc.).

VI.It is the policy of Ambetter of North Carolina that procedures used solely to improve appearance, and unrelated to gender expression, are not medically necessary, as they are considered cosmetic in nature.

VII. It is the policy of Ambetter of North Carolina that detransition procedures by gender- related hormone intervention, surgical intervention, or both, will be considered for medical necessity on a case-by-case basis.

Background The World Professional Association for Transgender Health (WPATH) is an international professional society dedicated to promoting the highest level of evidence-based principles for transgender and gender diverse (TGD) individuals.³ Gender identity is a person’s deepest inner sense of being female or male, which for many is established by the age of two through three years. Gender nonconformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex.⁴ Gender dysphoria refers to the discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics).⁴,⁵ Per WPATH, the focus of gender dysphoria is not on the individual’s gender identity, but on any of the distress or discomfort related to being TGD.³ WPATH states that gender incongruence is considered a condition with a focus on the TGD person’s experienced identity and any need for gender-affirming treatment that arises from this identity.³

Treatment to assist people with gender dysphoria is available and can help to find the gender identity and role that is comfortable for them. Treatment is very individualized and may or may not involve gender-affirming surgery or body modification. Treatment options include changes in gender expression and role; hormone therapy to feminize or masculinize the body; surgery to change primary and/or secondary sex characteristics; and psychotherapy. Many people who receive treatment for gender dysphoria will find a gender role and expression that is comfortable for them, regardless of whether they differ from the sex assigned to them at birth.

WPATH’s Standards of Care (SOC) are a series of flexible guidelines for clinical practice published by the society and are based on evidence and expert consensus.³ Version 8 of WPATH’s SOC were published in 2022, and these guidelines offer clinical guidance to health care professionals caring for TGD people and are intended to be adaptable to meet the diverse health care needs of this population.³

WPATH recommends that the assessment for GAMST in adults ≥ 18 years of age be completed by a provider who is licensed by their statutory body and hold, at a minimum, a master’s degree in a clinical field related to transgender health or equivalent further clinical training and be statutorily regulated (e.g., mental health professional, general medical practitioner, nurse, or other qualified health care provider). The provider(s) working with gender diverse adults should additionally meet all of the following:³

1. Identify co-existing mental health or other psychosocial concerns, distinguishing these from gender dysphoria, incongruence, and diversity;
2. Assess capacity to consent for treatment (capacity to consent is required for GAMST assessment);
3. Have experience or is qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity and is able to liaise with consultations from different disciplines within the field of transgender health for consultations and referral, if required;
4. Identify and exclude other possible causes of apparent gender incongruence prior to the initiation of gender-affirming treatments;
5. Ensure any mental or physical health conditions that could negatively impact the outcome of GAMSTs are assessed, with risks and benefits discussed, before a decision is made regarding treatment;
6. Assess the member/enrollee’s capacity to understand the effect of GAMST on reproduction and discuss reproduction options with the member/enrollee prior to the initiation of GAMST;
7. Assess and discuss the role of social transition with the member/enrollee requesting GAMST.

**Per North Carolina House Bill 808 G.S. 90-21.151-“It shall be unlawful for a medical professional to perform a surgical gender transition procedure on a minor or to prescribe, provide, or dispense puberty-blocking drugs or cross-sex hormones to a minor”. However, G.S. 90-21.152 describes when certain procedures are permitted.²

Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

CPT codes that may be considered part of gender-affirming surgery. This code list does not indicate if a procedure is or is not considered medically necessary.

CLINICAL POLICY

Gender-Affirming Procedures

3. Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022;23(Suppl 1):S1 to S259. Published 2022 Sep 6. doi:10.1080/26895269.2022.2100644
4. Knudson G, De Cuyper G, Bockting W. Recommendations for revision of the DSM diagnoses of gender identity disorders: Consensus statement of The World Professional Association for Transgender Health. Int J Transgend. 2012;12(2):115 to 118.
5. Fisk NM. Editorial: Gender dysphoria syndrome – the conceptualization that liberalizes indications for total gender reorientation and implies a broadly based multi-dimensional rehabilitative regimen. West J Med. 1974;120(5):386 to 391, May 1974.
6. Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington (DC): National Academies Press (US); 2011.
7. Health Technology Assessment. Sex reassignment surgery for the treatment of gender dysphoria. Hayes. www.hayes.com. August 01, 2018 (annual review July 27, 2022). Accessed August 6, 2025.
8. Levine DA; Committee On Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics 2013;132(1):e297 to e313. doi:10.1542/peds.2013-1283
9. Tangpricha V, Safer JD. Transgender women: Evaluation and management. UpToDate. www.uptodate.com. Updated October 12, 2023. Accessed August 6, 2025.
10. Tangpricha V, Safer JD. Transgender men: Evaluation and management. UpToDate. www.uptodate.com. Updated June 30, 2023. Accessed August 6, 2025.
11. The World Professional Association for Transgender Health, Inc. (WPATH). Position statement on medical necessity of treatment, sex reassignment, and insurance coverage in the U.S.A. https://wpath.org/wp-content/uploads/2024/11/WPATH-Position-on-Medical-Necessity-12-21-2016.pdf. Published December 21, 2016. Accessed August 6, 2025.
12. Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021;137(3):e75 to e88. doi:10.1097/AOG.0000000000004294
13. van de Grift TC, Elaut E, Cerwenka SC, Cohen-Kettenis PT, Kreukels BPC. Surgical Satisfaction, Quality of Life, and Their Association After Gender-Affirming Surgery: A Follow-up Study. J Sex Marital Ther. 2018;44(2):138 to 148. doi:10.1080/0092623X.2017.1326190
14. Papadopoulos NA, Lellé JD, Zavlin D, et al. Quality of Life and Patient Satisfaction Following Male-to-Female Sex Reassignment Surgery. J Sex Med. 2017;14(5):721 to 730. doi:10.1016/j.jsxm.2017.01.022
15. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Incongruent Persons: An Endocrine Society Clinical Practice Guideline [published correction appears in J Clin Endocrinol Metab. 2018 Feb 1;103(2):699] [published correction appears in J Clin Endocrinol Metab. 2018 Jul 1;103(7):2758 to 2759]. J Clin Endocrinol Metab. 2017;102(11):3869 to 3903. doi:10.1210/jc.2017-01658
16. Local coverage article: gender reassignment services for gender dysphoria (A53793). Centers for Medicare and Medicaid Services website. http://www.cms.hhs.gov/mcd/search.asp. Published October 01, 2015 (revised May 20, 2025). Accessed August 6, 2025.
17. Van Damme S, Cosyns M, Deman S, Van den Eede Z, Van Borsel J. The Effectiveness of Pitch-raising Surgery in Male-to-Female Transsexuals: A Systematic Review. J Voice. 2017;31(2):244.e1 to 244.e5. doi:10.1016/j.jvoice.2016.04.002
18. Mahfouda S, Moore JK, Siafakas A, et al. Gender-affirming hormones and surgery in transgender children and adolescents. Lancet Diabetes Endocrinol. 2019;7(6):484 to 498. doi:10.1016/S2213-8587(18)30305-X
19. Butler RM, Horenstein A, Gitlin L, et al. Social anxiety among transgender and gender nonconforming individuals: The role of gender-affirming medical interventions. J Abnorm Psychol. 2019;128(1):25 to 31. doi:10.1037/abn0000399
20. Ferrando C. Gender-affirming surgery: Male to female. UpToDate. www.uptodate.com. Updated July 10, 2024. Accessed August 6, 2025.
21. Ferrando C, Zhao LC, Nikolavsky D. Gender-affirming surgery: female to male. UpToDate. www.uptodate.com. Updated November 26, 2024. Accessed August 6, 2025.

Important Reminder

This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollee. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

©2018 Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. ou may not alter or remove any trademark, copyright or other notice contained herein. Centene® and Centene Corporation® are registered trademarks exclusively owned by Centene Corporation.

Page 14 of 14