Gender Dysphoria Treatment Form

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Gender Dysphoria Treatment Medical Guideline

Service: Gender Dysphoria Treatment

PUM 250-0039

Medical Guideline Committee Approval Q4-2025 Effective Date 03/01/2026

Note: Some services listed in this guideline may be specific exclusions of a member’s health plan.
Benefits vary by plan. Consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to these services.

This guideline is based on the World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transgender, and Gender Diverse People, 8th version, Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), and American Psychiatric Association recommendations as well as other evidence-based publications.

The 8th edition (SOC-8) from WPATH uses transgender and gender diverse (TGD) people throughout the document.

Related Medical Guideline:

• Septoplasty and Rhinoplasty Medical Guideline • Panniculectomy, Abdominoplasty, and Repair of Diastasis Recti Medical Guideline • Blepharoplasty, Blepharoptosis Repair, Brow lift, and Related Procedures Medical Guideline • Non-covered Services and Procedures Medical Guideline

Description:

Gender dysphoria is a condition in which there is a marked incongruence (discrepancy or conflict) between an individual’s physical or assigned (birth) gender and the gender with which the individual identifies.

Indications of Coverage:

In the absence of health plan limits, more than one gender transformation reassignment (which may include several staged surgeries) per lifetime will be considered experimental, investigational and unproven.

When criteria / requirements below are met, the following gender reassignment surgical procedures may be considered medically necessary:

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Female-to-Male (FtM)

1. Bilateral mastectomy

2. Hysterectomy (removal of uterus)

3. Metoidioplasty (creation of penis using clitoris)

4. Penile prosthesis

5. Phalloplasty (creation of penis)

6. Salpingo-oophorectomy (removal of fallopian tubes and ovaries)

7. Scrotoplasty (creation of scrotum)

8. Testicular prosthesis

9. Urethroplasty (reconstruction of male urethra)

10. Vaginectomy (removal of vagina)

11. Vulvectomy (removal of vulva)

12. Bilateral mastectomy may be done as a stand-alone procedure, without having genital reconstruction procedures. In those cases, the individual does not need to complete hormone therapy prior to procedure.

    Male-to-Female (MtF)

13. Clitoroplasty (creation of clitoris)

14. Labiaplasty (creation of labia)

15. Orchiectomy (removal of testicles)

16. Penectomy (removal of penis)

17. Urethroplasty (reconstruction of female urethra)

18. Vaginoplasty (creation of vagina)

19. Breast augmentation (augmentation mammoplasty and breast implants)

    A. Requirements for mastectomy for female-to-male (FtM) individuals or breast augmentation (augmentation mammoplasty and breast implants) in male-to-female (MtF) individuals:

20. Single letter of referral from a *qualified mental health professional; and

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2. Persistent, well-documented gender dysphoria; and

3. Capacity to make a fully informed decision and to consent for treatment; and

4. Age 18 years or older; OR less than 18 years old with the consent of both parents (or legal

   guardians). If one parent/guardian cannot provide consent (due to death or documented

   extenuating circumstances), then the consent of the remaining parent/guardian will be

   acceptable.

5. If significant medical or mental health concerns are present, they must be reasonably well

   controlled.

    Note: A trial of hormone therapy is not a prerequisite (required or necessary) to qualify for a mastectomy.

    It is recommended (although not required) that male-to-female individuals undergo feminizing hormone therapy for a minimum of 12 months prior to breast augmentation surgery in order to maximize breast growth and obtain better surgical results.

   Note: More than one breast augmentation is considered not medically necessary.

   B. Requirements for gonadectomy (hysterectomy and oophorectomy in female-to-male individuals and orchiectomy in male-to-female individuals)

6. Single letter of referral from a *qualified mental health professional; and

7. Persistent, well-documented gender dysphoria; and

8. Capacity to make a fully informed decision and to consent for treatment; and

9. Age 18 years or older; OR less than 18 years old with the consent of both parents (or legal guardians). If one parent/guardian cannot provide consent (due to death or documented extenuating circumstances), then the consent of the remaining parent/guardian will be acceptable.

10. If significant medical or mental health concerns are present, they must be reasonably well controlled; and

11. Twelve months of continuous hormone therapy as appropriate to the individual’s gender goals (unless the individual has a medical contraindication) or is otherwise unable or unwilling to take hormones).

    C. Requirements for genital reconstructive surgery

12. Single letter of referral from a *qualified mental health professional; and

13. Persistent, well-documented gender dysphoria; and

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3. Capacity to make a fully informed decision and to consent for treatment; and

4. Age 18 years or older; OR less than 18 years old with the consent of both parents (or legal guardians). If one parent/guardian cannot provide consent (due to death or documented extenuating circumstances), then the consent of the remaining parent/guardian will be acceptable.

5. If significant medical or mental health concerns are present, they must be reasonably well controlled; and

6. Twelve months of continuous hormone therapy as appropriate to the member’s gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones); and

7. Twelve months of living in a gender role that is congruent with their gender identity (real life experience).

   *Requirements for a Qualified Mental Health Professional:

8. Master’s degree or equivalent in a clinical behavioral science field granted by an institution accredited by the appropriate national accrediting board. The professional should also have documented credentials from the relevant licensing board or equivalent; and

9. Competence in using the Diagnostic Statistical Manual of Mental Disorders (5th Edition, DSM-5) and/or the International Classification of Disease for diagnostic purposes; and

10. Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria; and

11. Knowledgeable about gender nonconforming identities and expressions; and the assessment and treatment of gender dysphoria; and

12. Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars, obtaining supervision from a mental health professional with relevant experience, or participating in research related to gender nonconformity and gender dysphoria.

    *Note: Topical and oral testosterone/androgens are reviewed by Express Scripts.
    Testosterone/cypionate/enanthate may also be reviewed by Express Scripts when being self-administered.

    Limitations of Coverage:

    Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do

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intend to limit a list of services or examples, we state specifically that the list “is limited to.”

A. Review health plan and endorsements for exclusions and prior authorization or benefit requirements.

B. If used for a condition or diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition or diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

D. Reproductive services (including, but not limited to, sperm or oocyte preservation, cryopreservation of fertilized embryos) are often considered Health Plan exclusions and will not be covered (unless mandated by Federal or State legislation).

E. Certain ancillary procedures, including (but not limited to) the following, are considered exclusions of the health plan for all individuals or are considered cosmetic, when performed as part of gender reassignment:

1. Abdominoplasty (tummy tuck)

2. Bicep implantation

3. Blepharoplasty (eyelid surgery). See medical guideline: Blepharoplasty, Blepharoptosis Repair, Brow Lift, and Related Procedures for medical necessity criteria (Indications of Coverage) and Limitations of Coverage related to this.

4. Body contouring or body sculpting (such as, but not limited to fat transfer, lipoplasty, panniculectomy, Ultherapy™, CoolSculpting™).

5. Body lift procedures

6. Brachioplasty (arm lift)

7. Brow lift. See medical guideline: Blepharoplasty, Blepharoptosis Repair, Brow Lift, and Related Procedures for medical necessity criteria [Indications of Coverage] and Limitations of Coverage related to this.

8. Buttocks augmentation or buttocks enhancement procedures

9. Calf implants

10. Cheek, chin and nose implants

11. Chemical peels

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12. Dermabrasion

13. Face lift or forehead lift

14. Alteration of the skeletal structures of the face, forehead or chin (for facial reconstruction)

15. Genioplasty (chin surgery)

16. Hair removal (such as electrolysis, laser hair removal, waxing) except when being performed in advance of genital reconstructive purposes

17. Hair transplantation

18. Injection of collagen, fillers, or neurotoxins

19. Lip augmentation

20. Lip reduction

21. Liposuction (suction-assisted lipectomy)

22. Mastopexy

23. Neck tightening

24. Nipple/areola reconstruction (if done as a stand-alone procedure)

25. Otoplasty (ear shaping surgery)

26. Pectoral implants for chest masculinization

27. Removal of redundant skin

28. Reversal of genital surgery or reversal of surgery to revise secondary sexual characteristics.

29. Rhinoplasty

30. Skin resurfacing (such as dermabrasion, chemical peels, laser)

31. Speech therapy for the purpose of voice modification when there is no speech functional deficit present.

32. Thighplasty (Thigh lift)

33. Thyroid cartilage reduction/reduction thyroid chondroplasty/trachea shave (removal or reduction of the Adam’s apple).

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34. Torso masculinization or feminization

35. Voice modification surgery (such as laryngoplasty, glottoplasty, cricothyroid approximation, or shortening of the vocal cords).

36. Voice lessons or voice therapy

    Documentation Required:

    • Referral letter from a *qualified mental health professional containing all of the following:

37. Client’s general identifying characteristics (include pertinent clinical information such as preferred gender pronoun); and

38. Results of the client’s psychosocial assessment, including any diagnoses; and

39. The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date; and

40. An explanation that the WPATH criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery; and

41. A statement about the fact that informed consent has been obtained from the patient; and

42. A statement that the qualified mental health professional is available for coordination of care and how contact can be made.

     Note: See *Requirements for a Qualified Mental Health Professional in the Indications of Coverage section.

    • Medication records as applicable

    • Laboratory records if indicated

    • Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.

    • Medical record information (including continued need/use if applicable) and medical necessity. Office notes, Visual field report, Photographs

    • Correct coding for the item/service that meets all the coding guidelines.

    Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may

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not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

Gender Dysphoria treatments are considered necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical guideline.

Guideline Review History:

Implemented 08/21/17, 10/01/18, 10/01/19, 04/01/20, 01/01/21, 12/01/21, 03/01/23, 01/01/24, 11/01/24, 03/01/26 Medical Guideline Committee Approval 06/16/17, 06/15/18, 04/26/19, 11/22/19, 11/19/20, 11/18/21, 12/15/22, 12/14/23, 10/31/24, Q4 2025 Reviewed

06/15/18, 04/26/19, 11/22/19, 11/19/20, 12/15/22, 12/14/23, 10/31/24, Q4 2025 Revised 06/15/18 Developed 06/16/17 Note: Title of guideline changed from Treatment of Gender Dysphoria to Gender Dysphoria Treatment 06/15/18.

Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Note: This list does not apply to breast reconstruction procedures following mastectomy for breast cancer.

Code Description 11950 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); 1 CC OR LESS 11951 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); 1.1 TO 5.0 CC 11952 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); 5.1 TO 10.0 CC 11954 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (EG, COLLAGEN); OVER 10.0 CC

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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 14020 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS 14021 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM 14040 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS 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 14060 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS 14061 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM 14301 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM 14302 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; EACH ADDITIONAL 30.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 15734 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK 15738 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY 15750 FLAP; NEUROVASCULAR PEDICLE 15757 FREE SKIN FLAP WITH MICROVASCULAR ANASTOMOSIS 15758 FREE FASCIAL FLAP WITH MICROVASCULAR ANASTOMOSIS 15775 PUNCH GRAFT FOR HAIR TRANSPLANT; 1 TO 15 PUNCH GRAFTS 15776 PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15 PUNCH GRAFTS 15780 DERMABRASION; TOTAL FACE (EG, FOR ACNE SCARRING, FINE WRINKLING, RHYTIDS, GENERAL KERATOSIS) 15781 DERMABRASION; SEGMENTAL, FACE 15782 DERMABRASION; REGIONAL, OTHER THAN FACE 15783 DERMABRASION; SUPERFICIAL, ANY SITE (EG, TATTOO REMOVAL) 15788 CHEMICAL PEEL, FACIAL; EPIDERMAL 15789 CHEMICAL PEEL, FACIAL; DERMAL 15792 CHEMICAL PEEL, NONFACIAL; EPIDERMAL 15793 CHEMICAL PEEL, NONFACIAL; DERMAL 15819 CERVICOPLASTY 15820 BLEPHAROPLASTY, LOWER EYELID (unless medical guideline criteria for this service is met—see the medical guideline)

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15821 BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD (unless medical guideline criteria for this service is met—see the related medical guideline) 15822 BLEPHAROPLASTY, UPPER EYELID (unless medical guideline criteria for this service is met—see the related medical guideline) 15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID (unless medical guideline criteria for this service is met—see the related medical guideline) 15824 RHYTIDECTOMY; FOREHEAD 15825 RHYTIDECTOMY; NECK WITH PLATYSMAL TIGHTENING (PLATYSMAL FLAP, P-FLAP) 15826 RHYTIDECTOMY; GLABELLAR FROWN LINES 15828 RHYTIDECTOMY; CHEEK, CHIN, AND NECK 15829 RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP 15830 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY (unless medical necessity criteria for a panniculectomy are met; see related medical guideline for criteria). Panniculectomy is often an exclusion of the health plan. Note: This code may also be billed for abdominoplasty. Abdominoplasty is always considered cosmetic and NOT medically necessary. 15832 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); THIGH 15833 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); LEG 15834 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); HIP 15835 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); BUTTOCK 15836 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ARM 15837 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); FOREARM OR HAND 15838 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); SUBMENTAL FAT PAD 15839 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA 15847 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY), ABDOMEN (EG, ABDOMINOPLASTY) (INCLUDES UMBILICAL TRANSPOSITION AND FASCIAL PLICATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 15876 SUCTION ASSISTED LIPECTOMY; HEAD AND NECK 15877 SUCTION ASSISTED LIPECTOMY; TRUNK 15878 SUCTION ASSISTED LIPECTOMY; UPPER EXTREMITY 15879 SUCTION ASSISTED LIPECTOMY; LOWER EXTREMITY 17380 ELECTROLYSIS EPILATION, EACH 30 MINUTES (EXCEPT WHEN USED FOR GENITAL RECONSTRUCTION) 17999 UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS TISSUE 19303 MASTECTOMY, SIMPLE, COMPLETE 19304 MASTECTOMY, SUBCUTANEOUS 19316 MASTOPEXY

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19318 REDUCTION MAMMAPLASTY (unless medical guideline criteria for this service is met— see related medical guideline). Often an exclusion of the health plan as well.
19324 MAMMAPLASTY, AUGMENTATION; WITHOUT PROSTHETIC IMPLANT 19325 MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT 19340 IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION 19342 DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION 19350 NIPPLE/AREOLA RECONSTRUCTION (CONSIDERED INTEGRAL AND/OR NOT COVERED WHEN PERFORMED WITH REDUCTION MAMMOPLASTY) 20926 TISSUE GRAFTS, OTHER (EG, PARATENON, FAT, DERMIS) 21120 GENIOPLASTY; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, PROSTHETIC MATERIAL) 21121 GENIOPLASTY; SLIDING OSTEOTOMY, SINGLE PIECE 21122 GENIOPLASTY; SLIDING OSTEOTOMIES, 2 OR MORE OSTEOTOMIES (EG, WEDGE EXCISION OR BONE WEDGE REVERSAL FOR ASYMMETRICAL CHIN) 21123 GENIOPLASTY; SLIDING, AUGMENTATION WITH INTERPOSITIONAL BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 21125 AUGMENTATION, MANDIBULAR BODY OR ANGLE; PROSTHETIC MATERIAL 21127 AUGMENTATION, MANDIBULAR BODY OR ANGLE; WITH BONE GRAFT, ONLAY OR INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT) 21137 REDUCTION FOREHEAD; CONTOURING ONLY 21138 REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF PROSTHETIC MATERIAL OR BONE GRAFT (INCLUDES OBTAINING AUTOGRAFT) 21139 REDUCTION FOREHEAD; CONTOURING AND SETBACK OF ANTERIOR FRONTAL SINUS WALL 21172 RECONSTRUCTION SUPERIOR-LATERAL ORBITAL RIM AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION, WITH OR WITHOUT GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 21175 RECONSTRUCTION, BIFRONTAL, SUPERIOR-LATERAL ORBITAL RIMS AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION (EG, PLAGIOCEPHALY, TRIGONOCEPHALY, BRACHYCEPHALY), WITH OR WITHOUT GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 21179 RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS; WITH GRAFTS (ALLOGRAFT OR PROSTHETIC MATERIAL) 21180 RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFTS) 21208 OSTEOPLASTY, FACIAL BONES; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, OR PROSTHETIC IMPLANT) 21209 OSTEOPLASTY, FACIAL BONES; REDUCTION 21210 GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES OBTAINING GRAFT) 21270 MALAR AUGMENTATION, PROSTHETIC MATERIAL 21899 UNLISTED PROCEDURE, NECK OR THORAX 30400 RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP 30410 RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP

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30420 RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR (unless medical necessity criteria for rhinoplasty are met—see related medical guideline)

30430 RHINOPLASTY, SECONDARY; MINOR REVISION (SMALL AMOUNT OF NASAL TIP WORK) 30435 RHINOPLASTY, SECONDARY; INTERMEDIATE REVISION (BONY WORK WITH OSTEOTOMIES) 30450 RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES) 31599 UNLISTED PROCEDURE, LARYNX 31750 TRACHEOPLASTY; CERVICAL 31899 UNLISTED PROCEDURE, TRACHEA, BRONCHI 53410 URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA 53430 URETHROPLASTY, RECONSTRUCTION OF FEMALE URETHRA 54125 AMPUTATION OF PENIS; COMPLETE 54400 INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID) 54401 INSERTION OF PENILE PROSTHESIS; INFLATABLE (SELF-CONTAINED) 54405 INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR 54406 REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS 54408 REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS 54410 REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION 54411 REMOVAL AND REPLACEMENT OF ALL COMPONENTS OF A MULTI-COMPONENT INFLATABLE PENILE PROSTHESIS THROUGH AN INFECTED FIELD AT THE SAME OPERATIVE SESSION, INCLUDING IRRIGATION AND DEBRIDEMENT OF INFECTED TISSUE 54415 REMOVAL OF NON-INFLATABLE (SEMI-RIGID) OR INFLATABLE (SELF-CONTAINED) PENILE PROSTHESIS, WITHOUT REPLACEMENT OF PROSTHESIS 54416 REMOVAL AND REPLACEMENT OF NON-INFLATABLE (SEMI-RIGID) OR INFLATABLE (SELF-CONTAINED) PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION 54417 REMOVAL AND REPLACEMENT OF NON-INFLATABLE (SEMI-RIGID) OR INFLATABLE (SELF-CONTAINED) PENILE PROSTHESIS THROUGH AN INFECTED FIELD AT THE SAME OPERATIVE SESSION, INCLUDING IRRIGATION AND DEBRIDEMENT OF INFECTED TISSUE 54520 ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH 54660 INSERTION OF TESTICULAR PROSTHESIS (SEPARATE PROCEDURE) 54690 LAPAROSCOPY, SURGICAL; ORCHIECTOMY 55175 SCROTOPLASTY; SIMPLE 55180 SCROTOPLASTY; COMPLICATED 55970 INTERSEX SURGERY; MALE TO FEMALE

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55980 INTERSEX SURGERY; FEMALE TO MALE 56620 VULVECTOMY SIMPLE; PARTIAL 56625 VULVECTOMY SIMPLE; COMPLETE 56805 CLITOROPLASTY; FOR INTERSEX STATE 57110 VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL 57291 CONSTRUCTION OF ARTIFICIAL VAGINA; WITHOUT GRAFT 57292 CONSTRUCTION OF ARTIFICIAL VAGINA; WITH GRAFT 57335 VAGINOPLASTY FOR INTERSEX STATE 58150 TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S) 58260 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS 58262 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) 58291 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) 58544 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) 58550 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; 58552 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) 58553 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; 58554 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) 58570 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; 58571 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) 58572 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; 58573 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) 58661 LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY) 58720 SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE) 58940 OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL; 64856 SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR LEG, EXCEPT SCIATIC; INCLUDING TRANSPOSITION 64892 NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, ARM OR LEG; UP TO 4 CM LENGTH

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64896 NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS (CABLE), HAND OR FOOT; MORE THAN 4 CM LENGTH 67900 REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH) (unless medical guideline criteria for this service is met—see related medical guideline) 92507 TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL 92508 TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS C1813 PROSTHESIS, PENILE, INFLATABLE C2622 PROSTHESIS, PENILE, NON-INFLATABLE J9225 HISTRELIN IMPLANT (VANTAS), 50 MG J9226 HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG 0HX5XZZ TRANSFER CHEST SKIN, EXTERNAL APPROACH 0HX6XZZ TRANSFER BACK SKIN, EXTERNAL APPROACH 0HX7XZZ TRANSFER ABDOMEN SKIN, EXTERNAL APPROACH 0HX8XZZ TRANSFER BUTTOCK SKIN, EXTERNAL APPROACH 0HX0XZZ TRANSFER SCALP SKIN, EXTERNAL APPROACH 0HXBXZZ TRANSFER RIGHT UPPER ARM SKIN, EXTERNAL APPROACH 0HXCXZZ TRANSFER LEFT UPPER ARM SKIN, EXTERNAL APPROACH 0HXDXZZ TRANSFER RIGHT LOWER ARM SKIN, EXTERNAL APPROACH 0HXEXZZ TRANSFER LEFT LOWER ARM SKIN, EXTERNAL APPROACH 0HXHXZZ TRANSFER RIGHT UPPER LEG SKIN, EXTERNAL APPROACH 0HXJXZZ TRANSFER LEFT UPPER LEG SKIN, EXTERNAL APPROACH OHXKXZZ TRANSFER RIGHT LOWER LEG SKIN, EXTERNAL APPROACH 0HXLXZZ TRANSFER LEFT LOWER LEG SKIN, EXTERNAL APPROACH 0HXKXZZ TRANSFER RIGHT LOWER LEG SKIN, EXTERNAL APPROACH 0CX30ZZ TRANSFER SOFT PALATE, OPEN APPROACH 0CX3XZZ TRANSFER SOFT PALATE, EXTERNAL APPROACH 0CX40ZZ TRANSFER BUCCAL MUCOSA, OPEN APPROACH 0CX4XZZ TRANSFER BUCCAL MUCOSA, EXTERNAL APPROACH 0CX50ZZ TRANSFER UPPER GINGIVA, OPEN APPROACH 0CX5XZZ TRANSFER UPPER GINGIVA, EXTERNAL APPROACH 0CX60ZZ TRANSFER LOWER GINGIVA, OPEN APPROACH 0CX6XZZ TRANSFER LOWER GINGIVA, EXTERNAL APPROACH 0HX1XZZ TRANSFER FACE SKIN, EXTERNAL APPROACH 0HX4XZZ TRANSFER NECK SKIN, EXTERNAL APPROACH 0HX9XZZ TRANSFER PERINEUM SKIN, EXTERNAL APPROACH 0HXAXZZ TRANSFER INGUINAL SKIN, EXTERNAL APPROACH

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0HXBXZZ TRANSFER RIGHT UPPER ARM SKIN, EXTERNAL APPROACH 0HXCXZZ TRANSFER LEFT UPPER ARM SKIN, EXTERNAL APPROACH 0HXFXZZ TRANSFER RIGHT HAND SKIN, EXTERNAL APPROACH 0HXGXZZ TRANSFER LEFT HAND SKIN, EXTERNAL APPROACH 0HXMXZZ TRANSFER RIGHT FOOT SKIN, EXTERNAL APPROACH 0HXNXZZ TRANSFER LEFT FOOT SKIN, EXTERNAL APPROACH 0KXF0Z0 TRANSFER RIGHT TRUNK MUSCLE WITH SKIN, OPEN APPROACH 0KXF0Z1 TRANSFER RIGHT TRUNK MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXF0Z2 TRANSFER RIGHT TRUNK MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXF0Z5 TRANSFER RIGHT TRUNK MUSCLE, LATISSIMUS DORSI MYOCUTANEOUS FLAP, OPEN APPROACH 0KXF027 TRANSFER RIGHT TRUNK MUSCLE, DEEP INFERIOR EPIGASTRIC ARTERY PERFORATOR FLAP, OPEN APPROACH 0KXF0Z8 TRANSFER RIGHT TRUNK MUSCLE, SUPERFICIAL INFERIOR EPIGASTRIC ARTERY FLAP, OPEN APPROACH 0KXF0Z9 TRANSFER RIGHT TRUNK MUSCLE, GLUTEAL ARTERY PERFORATOR FLAP, OPEN APPROACH 0KXF0ZZ TRANSFER RIGHT TRUNK MUSCLE, OPEN APPROACH 0KXG0Z0 TRANSFER LEFT TRUNK MUSCLE WITH SKIN, OPEN APPROACH 0KXG0Z1 TRANSFER LEFT TRUNK MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXG0Z2 TRANSFER LEFT TRUNK MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXG0Z5 TRANSFER LEFT TRUNK MUSCLE, LATISSIMUS DORSI MYOCUTANEOUS FLAP, OPEN APPROACH 0KXG0Z7 TRANSFER LEFT TRUNK MUSCLE, DEEP INFERIOR EPIGASTRIC ARTERY PERFORATOR FLAP, OPEN APPROACH 0KXG0Z8 TRANSFER LEFT TRUNK MUSCLE, SUPERFICIAL INFERIOR EPIGASTRIC ARTERY FLAP, OPEN APPROACH 0KXG0Z9 TRANSFER LEFT TRUNK MUSCLE, GLUTEAL ARTERY PERFORATOR FLAP, OPEN APPROACH 0KXG0ZZ TRANSFER LEFT TRUNK MUSCLE, OPEN APPROACH 0KXH0Z0 TRANSFER RIGHT THORAX MUSCLE WITH SKIN, OPEN APPROACH 0KXH0Z1 TRANSFER RIGHT THORAX MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXH0Z2 TRANSFER RIGHT THORAX MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXJ0Z0 TRANSFER LEFT THORAX MUSCLE WITH SKIN, OPEN APPROACH 0KXJ0Z1 TRANSFER LEFT THORAX MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXJ0Z2 TRANSFER LEFT THORAX MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH

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0KXK0Z0 TRANSFER RIGHT ABDOMEN MUSCLE WITH SKIN, OPEN APPROACH 0KXK0Z1 TRANSFER RIGHT ABDOMEN MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXK0Z2 TRANSFER RIGHT ABDOMEN MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXK0ZZ TRANSFER RIGHT ABDOMEN MUSCLE, OPEN APPROACH 0KXL0Z0 TRANSFER LEFT ABDOMEN MUSCLE WITH SKIN, OPEN APPROACH 0KXL0Z1 TRANSFER LEFT ABDOMEN MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXL0Z2 TRANSFER LEFT ABDOMEN MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXL0ZZ TRANSFER LEFT ABDOMEN MUSCLE, OPEN APPROACH 0KXN0Z0 TRANSFER RIGHT HIP MUSCLE WITH SKIN, OPEN APPROACH 0KXN0Z1 TRANSFER RIGHT HIP MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXN0Z2 TRANSFER RIGHT HIP MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXN0ZZ TRANSFER RIGHT HIP MUSCLE, OPEN APPROACH 0KXP0Z0 TRANSFER LEFT HIP MUSCLE WITH SKIN, OPEN APPROACH 0KXP0Z1 TRANSFER LEFT HIP MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXP0Z2 TRANSFER LEFT HIP MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXP0ZZ TRANSFER LEFT HIP MUSCLE, OPEN APPROACH 0KXQ0Z0 TRANSFER RIGHT UPPER LEG MUSCLE WITH SKIN, OPEN APPROACH 0KXQ0Z1 TRANSFER RIGHT UPPER LEG MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXQ0Z2 TRANSFER RIGHT UPPER LEG MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXQ0ZZ TRANSFER RIGHT UPPER LEG MUSCLE, OPEN APPROACH 0KXR0Z0 TRANSFER LEFT UPPER LEG MUSCLE WITH SKIN, OPEN APPROACH 0KXR0Z1 TRANSFER LEFT UPPER LEG MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXR0Z2 TRANSFER LEFT UPPER LEG MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXR0ZZ TRANSFER LEFT UPPER LEG MUSCLE, OPEN APPROACH 0KXS0Z0 TRANSFER RIGHT LOWER LEG MUSCLE WITH SKIN, OPEN APPROACH 0KXS0Z1 TRANSFER RIGHT LOWER LEG MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXS0Z2 TRANSFER RIGHT LOWER LEG MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXS0ZZ TRANSFER RIGHT LOWER LEG MUSCLE, OPEN APPROACH 0KXT0Z0 TRANSFER LEFT LOWER LEG MUSCLE WITH SKIN, OPEN APPROACH

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0KXT0Z1 TRANSFER LEFT LOWER LEG MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXT0Z2 TRANSFER LEFT LOWER LEG MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXT0ZZ TRANSFER LEFT LOWER LEG MUSCLE, OPEN APPROACH 0KXV0Z0 TRANSFER RIGHT FOOT MUSCLE WITH SKIN, OPEN APPROACH 0KXV0Z1 TRANSFER RIGHT FOOT MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXV0Z2 TRANSFER RIGHT FOOT MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXV0ZZ TRANSFER RIGHT FOOT MUSCLE, OPEN APPROACH 0KXW0Z0 TRANSFER LEFT FOOT MUSCLE WITH SKIN, OPEN APPROACH 0KXW0Z1 TRANSFER LEFT FOOT MUSCLE WITH SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXW0Z2 TRANSFER LEFT FOOT MUSCLE WITH SKIN AND SUBCUTANEOUS TISSUE, OPEN APPROACH 0KXW0ZZ TRANSFER LEFT FOOT MUSCLE, OPEN APPROACH 0HTT0ZZ RESECTION OF RIGHT BREAST, OPEN APPROACH 0HTU0ZZ RESECTION OF LEFT BREAST, OPEN APPROACH 0HTV0ZZ RESECTION OF BILATERAL BREAST, OPEN APPROACH 0HBT0ZZ EXCISION OF RIGHT BREAST, OPEN APPROACH 0HBU0ZZ EXCISION OF LEFT BREAST, OPEN APPROACH 0HBV0ZZ EXCISION OF BILATERAL BREAST, OPEN APPROACH 0H0T0ZZ ALTERATION OF RIGHT BREAST, OPEN APPROACH 0H0U0ZZ ALTERATION OF LEFT BREAST, OPEN APPROACH 0H0V0ZZ ALTERATION OF BILATERAL BREAST, OPEN APPROACH 0HBT0ZZ EXCISION OF RIGHT BREAST, OPEN APPROACH 0HBU0ZZ EXCISION OF LEFT BREAST, OPEN APPROACH 0HBV0ZZ EXCISION OF BILATERAL BREAST, OPEN APPROACH 0TQD0ZZ REPAIR URETHRA, OPEN APPROACH 0TUD07Z SUPPLEMENT URETHRA WITH AUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH 0VTS0ZZ RESECTION OF PENIS, OPEN APPROACH 0VTSXZZ RESECTION OF PENIS, EXTERNAL APPROACH 0VUS0JZ SUPPLEMENT PENIS WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH 0VPS0JZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM PENIS, OPEN APPROACH 0VWS0JZ REVISION OF SYNTHETIC SUBSTITUTE IN PENIS, OPEN APPROACH 0V2SXYZ CHANGE OTHER DEVICE IN PENIS, EXTERNAL APPROACH 0JBB0ZZ EXCISION OF PERINEUM SUBCUTANEOUS TISSUE AND FASCIA, OPEN APPROACH 0VBS0ZZ EXCISION OF PENIS, OPEN APPROACH 0VPS0JZ REMOVAL OF SYNTHETIC SUBSTITUTE FROM PENIS, OPEN APPROACH 0VUS0JZ SUPPLEMENT PENIS WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH 0VR90JZ REPLACEMENT OF RIGHT TESTIS WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH

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0VRB0JZ REPLACEMENT OF LEFT TESTIS WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH 0VRC0JZ REPLACEMENT OF BILATERAL TESTES WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH 0VT90ZZ RESECTION OF RIGHT TESTIS, OPEN APPROACH 0VTB0ZZ RESECTION OF LEFT TESTIS, OPEN APPROACH 0VTC0ZZ RESECTION OF BILATERAL TESTES, OPEN APPROACH 0VR90JZ REPLACEMENT OF RIGHT TESTIS WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH 0VT94ZZ RESECTION OF RIGHT TESTIS, PERCUTANEOUS ENDOSCOPIC APPROACH 0VTB4ZZ RESECTION OF LEFT TESTIS, PERCUTANEOUS ENDOSCOPIC APPROACH 0VTC4ZZ RESECTION OF BILATERAL TESTES, PERCUTANEOUS ENDOSCOPIC APPROACH 0VQ50ZZ REPAIR SCROTUM, OPEN APPROACH 0VU507Z SUPPLEMENT SCROTUM WITH AUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH 0UT04ZZ RESECTION OF RIGHT OVARY, PERCUTANEOUS ENDOSCOPIC APPROACH 0UT14ZZ RESECTION OF LEFT OVARY, PERCUTANEOUS ENDOSCOPIC APPROACH 0UT24ZZ RESECTION OF BILATERAL OVARIES, PERCUTANEOUS ENDOSCOPIC APPROACH 0UT54ZZ RESECTION OF RIGHT FALLOPIAN TUBE, PERCUTANEOUS ENDOSCOPIC APPROACH 0UT64ZZ RESECTION OF LEFT FALLOPIAN TUBE, PERCUTANEOUS ENDOSCOPIC APPROACH 0UT74ZZ RESECTION OF BILATERAL FALLOPIAN TUBES, PERCUTANEOUS ENDOSCOPIC APPROACH 0UT94ZL RESECTION OF UTERUS, SUPRACERVICAL, PERCUTANEOUS ENDOSCOPIC APPROACH 0UT94ZZ RESECTION OF UTERUS, PERCUTANEOUS ENDOSCOPIC APPROACH 0UT9FZZ RESECTION OF UTERUS, VIA NATURAL OR ARTIFICIAL OPENING WITH PERCUTANEOUS ENDOSCOPIC ASSISTANCE 0UTC7ZZ RESECTION OF CERVIX, VIA NATURAL OR ARTIFICIAL OPENING 0UT07ZZ RESECTION OF RIGHT OVARY, VIA NATURAL OR ARTIFICIAL OPENING 0UT17ZZ RESECTION OF LEFT OVARY, VIA NATURAL OR ARTIFICIAL OPENING 0UT27ZZ RESECTION OF BILATERAL OVARIES, VIA NATURAL OR ARTIFICIAL OPENING 0UT57ZZ RESECTION OF RIGHT FALLOPIAN TUBE, VIA NATURAL OR ARTIFICIAL OPENING 0UT67ZZ RESECTION OF LEFT FALLOPIAN TUBE, VIA NATURAL OR ARTIFICIAL OPENING 0UT77ZZ RESECTION OF BILATERAL FALLOPIAN TUBES, VIA NATURAL OR ARTIFICIAL OPENING 0UT9FZZ RESECTION OF UTERUS, VIA NATURAL OR ARTIFICIAL OPENING WITH PERCUTANEOUS ENDOSCOPIC ASSISTANCE 0UT94ZZ RESECTION OF UTERUS, PERCUTANEOUS ENDOSCOPIC APPROACH 0UTC4ZZ RESECTION OF CERVIX, PERCUTANEOUS ENDOSCOPIC APPROACH 0UB04ZZ EXCISION OF RIGHT OVARY, PERCUTANEOUS ENDOSCOPIC APPROACH 0UB14ZZ EXCISION OF LEFT OVARY, PERCUTANEOUS ENDOSCOPIC APPROACH 0UB24ZZ EXCISION OF BILATERAL OVARIES, PERCUTANEOUS ENDOSCOPIC APPROACH 0UB54ZZ EXCISION OF RIGHT FALLOPIAN TUBE, PERCUTANEOUS ENDOSCOPIC APPROACH 0UB64ZZ EXCISION OF LEFT FALLOPIAN TUBE, PERCUTANEOUS ENDOSCOPIC APPROACH 0UB74ZZ EXCISION OF BILATERAL FALLOPIAN TUBES, PERCUTANEOUS ENDOSCOPIC APPROACH

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0UB00ZZ EXCISION OF RIGHT OVARY, OPEN APPROACH 0UB10ZZ EXCISION OF LEFT OVARY, OPEN APPROACH 0UB20ZZ EXCISION OF BILATERAL OVARIES, OPEN APPROACH 0UB50ZZ EXCISION OF RIGHT FALLOPIAN TUBE, OPEN APPROACH 0UB60ZZ EXCISION OF LEFT FALLOPIAN TUBE, OPEN APPROACH 0UB70ZZ EXCISION OF BILATERAL FALLOPIAN TUBES, OPEN APPROACH 0UT00ZZ RESECTION OF RIGHT OVARY, OPEN APPROACH 0UT10ZZ RESECTION OF LEFT OVARY, OPEN APPROACH 0UT20ZZ RESECTION OF BILATERAL OVARIES, OPEN APPROACH 0UT50ZZ RESECTION OF RIGHT FALLOPIAN TUBE, OPEN APPROACH 0UT60ZZ RESECTION OF LEFT FALLOPIAN TUBE, OPEN APPROACH 0UT70ZZ RESECTION OF BILATERAL FALLOPIAN TUBES, OPEN APPROACH 01Q40ZZ REPAIR ULNAR NERVE, OPEN APPROACH 01Q50ZZ REPAIR MEDIAN NERVE, OPEN APPROACH 01Q60ZZ REPAIR RADIAL NERVE, OPEN APPROACH 01QG0ZZ REPAIR TIBIAL NERVE, OPEN APPROACH 01QH0ZZ REPAIR PERONEAL NERVE, OPEN APPROACH 01S40ZZ REPOSITION ULNAR NERVE, OPEN APPROACH 01S50ZZ REPOSITION MEDIAN NERVE, OPEN APPROACH 01S60ZZ REPOSITION RADIAL NERVE, OPEN APPROACH 01SG0ZZ REPOSITION TIBIAL NERVE, OPEN APPROACH 01SH0ZZ REPOSITION PERONEAL NERVE, OPEN APPROACH 01BH0ZZ EXCISION OF PERONEAL NERVE, OPEN APPROACH 01U407Z SUPPLEMENT ULNAR NERVE WITH AUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH 01U40KZ SUPPLEMENT ULNAR NERVE WITH NONAUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH 01U507Z SUPPLEMENT MEDIAN NERVE WITH AUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH 01U50KZ SUPPLEMENT MEDIAN NERVE WITH NONAUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH 01U607Z SUPPLEMENT RADIAL NERVE WITH AUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH 01U60KZ SUPPLEMENT RADIAL NERVE WITH NONAUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH 01UD0KZ SUPPLEMENT FEMORAL NERVE WITH NONAUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH 01UF0KZ SUPPLEMENT SCIATIC NERVE WITH NONAUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH

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01UG07Z SUPPLEMENT TIBIAL NERVE WITH AUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH 01UG0KZ SUPPLEMENT TIBIAL NERVE WITH NONAUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH 01UH0KZ SUPPLEMENT PERONEAL NERVE WITH NONAUTOLOGOUS TISSUE SUBSTITUTE, OPEN APPROACH