189 Form

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Medical Policy Gender Affirming Services (Transgender and Gender Diverse Services)

Policy Number: 189

BCBSA Reference Number: N/A NCD/LCD: N/A Related Policies
• Assisted Reproductive Services, #086 • Outpatient Psychotherapy, #423 • Prior Authorization Request for Gender Affirming Services (Transgender and Gender Diverse Services) Form, #901 • Prior Authorization Request for Electrolysis for Gender Affirming Services (Transgender and Gender Diverse Services) Form, #902 Table of Contents Definitions .................................................................................................................................................... 2 Policy and Products .................................................................................................................................... 2 Hormone Therapy ....................................................................................................................................... 2 Puberty Blockers..................................................................................................................................... 2 Gender Affirming Hormone Therapy ...................................................................................................... 3 Behavioral Health ........................................................................................................................................ 3 Fertility Preservation .................................................................................................................................. 3 Surgical Services ........................................................................................................................................ 3 Facial feminization or Masculinization .................................................................................................... 5 Vocal Cord Surgery ................................................................................................................................ 5 Chest Procedures ................................................................................................................................... 5 Genital Procedures ................................................................................................................................. 6 Electrolysis .............................................................................................................................................. 6 Surgical Revisions/Reconstruction .......................................................................................................... 6 Surgical Services for Adolescents ............................................................................................................ 7 Speech Therapy/Voice Training ................................................................................................................ 7

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Not Medically Necessary/Not Covered Services ..................................................................................... 7 Prior Authorization Information ................................................................................................................. 7 Policy History .............................................................................................................................................. 8 Information Pertaining to All Blue Cross Blue Shield Medical Policies .............................................. 10 References ................................................................................................................................................. 10 CPT Codes / HCPCS Codes / ICD Codes ................................................................................................ 12 Endnotes .................................................................................................................................................... 32

Definitions This policy addresses gender affirming services for transgender and gender diverse individuals when gender identity differs from assigned sex at birth.

Please Note: According to the American Psychiatric Association, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines gender dysphoria as a condition where a person’s gender at birth is “contrary to the one they identify with.” This definition replaces the criteria for gender identity disorder which will no longer be used in DSM-5. However, ICD-10 codes continue to use the term gender identity disorder, and providers will need to submit claims for coverage using this diagnosis.

Policy1 and Products Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Hormone Therapy Puberty Blockers Gonadotropin-releasing hormone (GnRH) analog treatment for gender non-conforming adolescents seeking to delay puberty is covered at the discretion of the treating provider*. GnRH analogs may be used to either allow members more time for decision making purposes or as an initial step prior to further gender affirming services such as hormone therapy.

Treatment options include but are not limited to:
• Lupron • Supprelin LA • Vantas
• Triptodur (triptorelin).

*The following criteria are recommended by World Professional Association for Transgender Health (WPATH) Standards of Care 8th edition as minimum criteria prior to starting puberty suppressing hormones:

1. The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed)
2. Gender dysphoria emerged or worsened with the onset of puberty
3. Any co-existing psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment
4. The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.

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Gender Affirming Hormone Therapy Gender affirming hormone therapy is covered at the discretion of the treating provider. Gender affirming hormone therapy options include but are not limited to: • Estrogen, androgen reducing medications (bicalutamide, spironolactone, GnRH agonists, 5-alpha reductase inhibitors), progestins and testosterone.

Methods of administration vary between these products and may be subject to formulary or tiering restrictions.

Behavioral Health Supportive behavioral health services for transgender and gender diverse members with or without additional behavioral health diagnoses are covered.

Examples of covered behavioral health services include: • Initial evaluation • Counseling • Psychotherapy.

Behavioral health or substance use disorder services related to diagnoses other than gender identity disorder or gender dysphoria may be governed by other medical policies or the member’s subscriber certificate based on the service being rendered. Please see related policies section.

Fertility Preservation Oocyte, embryo, or sperm retrieval, freezing and storage for up to 24 months for transgender members prior to undergoing genital gender affirming surgery or hormone therapy* may be considered MEDICALLY NECESSARY. Adequate sperm or egg evaluation would be needed to be eligible. (See medical policy #086, Infertility Diagnosis and Treatment)

Per medical policy #086 Infertility Diagnosis and Treatment, cryopreservation is limited to one cycle only.

*Inclusive of members who have already started hormone therapy. These members are expected to stop and assess sperm/egg quality prior to cryopreservation.

Surgical Services Gender affirming surgeries are considered MEDICALLY NECESSARY when criteria in Table 1 are met AND any additional criteria specific to surgical types in Table 2 are met.

Table 1 All gender affirming surgical services must meet ALL of the following criteria to be considered MEDICALLY NECESSARY • Age ≥ 18
• The member has been diagnosed with gender dysphoria (ICD-10 codes F64.0-F64.9 gender identity disorder), and meets ALL the following indications: o The desire to live and be accepted as a member of another gender other than one’s assigned sex, typically accompanied by the desire to make the physical body as congruent as possible with the identified gender through surgery and hormone treatment. o The new gender identity should be present for at least 12 months. o The member has a consistent, stable gender identity that is well documented by their treating providers, and when possible, lives as their affirmed gender in places where it is safe to do so.
o The gender dysphoria (ICD-10 codes F64.0-F64.9 gender identity disorder) is not a symptom of another mental disorder.

Table 2

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Procedure Category Covered Procedures Additional Criteria/Notes

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Facial feminization or Masculinization • Forehead contouring
• Orbital contouring/Osteoplasty facial reduction
• Scalp advancement (only as needed in conjunction with forehead contouring).
• Rhinoplasty • Mandible reconstruction • Trachea shave • Blepharoplasty • Brow lift • Cheek augmentation • Face lift or liposuction (only as needed in conjunction with one of the above procedures). • Neck lift (only if the excess skin impairs the outcome of the covered facial feminization or masculinization procedures).

Surgical procedures may be done in stages as needed. Vocal Cord Surgery Wendler Glottoplasty for transfeminine members The treating surgeon must hold board certification in Otolaryngology-Head and Neck Surgery.

It is recommended that members undergoing voice feminization surgery also consult a voice and communication specialist to maximize the surgical outcome, help protect vocal health and learn non-pitch related aspects of communication.

Chest Procedures • Mastectomy and/or creation of a male chest (with or without body contouring) for transmasculine or gender diverse members.

• Breast augmentation (with or without body contouring) for transfeminine members.

Hormone therapy is not required for transmasculine or gender diverse members requesting surgical chest procedures.

For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is provided under the supervision of a licensed clinician.

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Genital Procedures • Genital gender affirming surgery for transmasculine, transfeminine or gender diverse members. • Penile construction following transgender surgery using Alloderm is covered.1

For those candidates without a medical contraindication, the candidate has undergone a minimum of 6 months of continuous hormonal therapy that is provided under the supervision of a licensed clinician.

Genital surgery for transmasculine, transfeminine or gender diverse members may be considered medically necessary when above medically necessary criteria are met as documented by two licensed and treating clinicians (e.g., behavioral health professional, primary care provider, or surgeon).

Surgical procedures may be done in stages as needed.

Genital surgery for Mayer-Rokitansky- Küster-Hauser (MRKH) syndrome (a disorder that occurs in females and mainly affects the reproductive system) does not require two letters of medical necessity.

Electrolysis Electrolysis and/or laser hair removal performed by a licensed and/or certified provider, for the removal of hair on skin being used for genital gender affirmation surgery.

Up to 12 electrolysis and/or laser hair removal treatments may be used in preparation for genital surgery for transmasculine, transfeminine or gender diverse members.

Greater than 12 electrolysis and/or laser hair removal treatments will require prior authorization with a subsequent letter of medical necessity.

Please refer to the Electrolysis for Gender Affirming Services (Transgender Services) Prior Authorization Request Form #902.

Electrolysis and/or laser hair removal for any other part of the body for any other indication is not covered.

Surgical Revisions/Reconstruction Reconstructive surgery following gender affirmation surgery (including facial surgery) may be considered MEDICALLY NECESSARY when it is performed to: • Correct complications resulting from the initial surgery OR • Correct functional impairment resulting from initial surgery.

Reconstructive surgery following gender affirmation surgery is NOT MEDICALLY NECESSARY to reverse natural signs of aging or if the member is not satisfied with the surgical result.

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Surgical Services for Adolescents Members <18 years of age will be considered on a case-by-case basis.

In addition to meeting the above criteria, providers requesting surgery for members <18 will need to provide documentation supporting ALL of the following:

• The member has adequate home support. • The member has realistic expectations regarding the possibilities and limitations of surgery and a full understanding of the long-term consequences of surgical procedures.
• The member has been assessed for any co-existing mental health concerns and is not requesting surgery as an initial response to gender dysphoric puberty.

Speech Therapy/Voice Training Feminizing or masculinizing speech therapy and/or voice training services for transgender and gender diverse members with or without additional health diagnoses are covered services.

Not Medically Necessary/Not Covered Services The following procedures are considered INVESTIGATIONAL and are not covered including but not limited to: • Body contouring unrelated to chest surgery • Rib Remodeling • Buttocks enhancement
• Tracheal implant
• Breast lift • Lip enhancement as a standalone procedure
• Lip lift • Monsplasty • Neck lift (as a stand-alone procedure) • Buccal Fat Pad removal • Dermabrasion • Chemical peel • Hair transplant • Electrolysis (except for genital surgery as noted above).

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) • Prior authorization is required for surgical services and fertility preservation.
• Prior authorization is not required for surgically implanted puberty blockers.
Commercial PPO and Indemnity • Prior authorization is required for surgical services and fertility preservation.
• Prior authorization is not required for surgically implanted puberty blockers. Medicare HMO BlueSM • Prior authorization is required for surgical services, speech therapy and/or voice training services only.*

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• Prior authorization is not required for surgically implanted puberty blockers. Medicare PPO BlueSM Prior authorization is not required.

Note: Prior authorization is not required on HCPCS codes: J3316, J9219, J9225, and J9226.

*Prior Authorization Request Form: Gender Affirming Services (Transgender Services)
The relevant form must be completed and faxed to: Medical and Surgical: 1-888-282-0780; Medicare Advantage: 1-800-447-2994; BCBSMA Employees: 617-246-4299 Click here for:
• Prior Authorization Request for Gender Affirming Services (Transgender Services) Form #901 • Prior Authorization Request for Electrolysis for Gender Affirming Services (Transgender Services) Form #902

Policy History Date Action 5/2026 Clarifications made to noncovered section. 5/1/2026 11/2025 Annual policy update. Description, summary and references reviewed. No changes to policy statements made. Clarified Coding Information. 11/1/2025.
1/2025 Investigational indications revised. 6/2024 Policy updated to clarify coverage for facial feminization procedures ie., orbital contouring. Clarified non-covered services list to specify monsplasty. 6/1/2024.
12/2023 Investigational/non-covered services added to non-covered section. Coding section clarified. Removal of hysterectomy and orchiectomy codes from prior authorization coding section. 12/2023. 2/2023 Annual policy update. WPATH version 8 (9/2022) guidelines and references reviewed and added. Clarifications made to section on hormone therapy. Clarified coding information. 2/2023.
12/2021 Policy statement on surgical procedures revised to clarify that surgical procedures may be done in stages as needed. Policy statement on facial feminization or masculinization clarified to include scalp advancement (only as needed in conjunction with forehead contouring). Policy statement revised to clarify that hormone therapy is not required for transmasculine or gender diverse members requesting surgical chest procedures. Effective 12/2021 10/2021 Policy revised. Effective 10/1/2021.
• To include new medically necessary statements for vocal cord surgery for transfeminine members.
Policy clarified. Effective 10/1/2021.
• To indicate chest procedures may be done with or without body contouring.
Policy reformatted for clarity.
6/2021 Policy statement clarified to include neck lift as a covered procedure only if the excess skin impairs the outcome of the covered facial feminization or masculinization procedures. Prior authorization table updated to clarify that prior authorization is not required for surgically implanted puberty blockers. 5/2021 Policy statement on fertility preservation clarified to meet the intent of the policy. Inclusive of members prior to gender affirmation surgery or hormone treatment (for members who have already started hormone therapy, they are expected to stop and assess sperm/egg quality prior to cryopreservation). Prior authorization is required for fertility preservation.
4/2021 Policy statement on oocyte, embryo, or sperm retrieval, freezing and storage for transgender members revised to clarify fertility preservation criteria prior to genital gender affirming surgery. Clarified that adequate sperm or egg evaluation would be needed to be eligible. 1/2021 Clarified coding information.

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12/2020 Penile construction following transgender surgery using Alloderm is covered. Clarified coding information. Effective 12/9/2020. 10/2020 Clarified coding information. 8/2020 Clarified coding information. 5/2020 Electrolysis and/or laser hair removal treatments revised. Up to 12 electrolysis and/or laser hair removal treatments may be used following the approval of genital surgery for transmasculine, transfeminine or gender diverse members. Greater than 12 electrolysis and/or laser hair removal treatments will require prior authorization with subsequent letter of medical necessity. Effective 5/1/2020. 1/2020 Clarified coding information. 11/2019 Clarified coding information. 9/2019 Policy revised. Effective 9/1/2019. • To include not medically necessary statements on breast lift.
• To include new medically necessary statements for feminizing or masculinizing speech therapy and/or voice training services. • To indicate that prior authorization is required for Medicare HMO. Policy clarified. Effective 9/1/2019. • To reflect current terminology i.e., gender identity, gender diverse. • To include bicalutamide for gender affirming hormone therapy • Medically necessary statement on electrolysis or laser hair removal edited to remove skin graft donor site. 3/2019 Policy updated to include clarifications to surgical revisions. Effective 3/1/2019. 2/2019 Policy revised: Effective 2/1/2019. • To include new medically necessary statements on hormone therapy/puberty blockers; gender-affirming hormone therapy; surgical services for adolescents; supportive behavioral health services. • To include vocal cord surgery as investigational procedure.
• Revised policy statements on facial procedures; chest procedures; genital procedures and electrolysis. • Speech therapy/voice training feminizing or masculinizing speech therapy added as not covered. • New references added 10/2018 Clarified coding information. 12/2017 Medically necessary criteria revised. New investigational indications described.
Clarified coding information. New references added. Effective 12/1/2017.
4/2017 Clarified coding information. 2/2017 Clarified coding information. 4/2016 Electrolysis added as medically necessary prior to sex reassignment surgery.
Clarified coding information. Clarified cryopreservation statement. Effective 4/1/2016.
10/2015 Clarified coding information. 9/2015 Clarified coding information. 8/2015 Ongoing coverage on cryopreservation for transgender members added. Statement transferred from medical policy #086, Infertility Diagnosis and Treatment. 4/2015 Coverage for facial surgical procedures and documentation requirement clarified.
Effective 4/1/2015. 11/2014 Medically necessary statement clarified. Effective 11/14/2014. 10/2014 Coding information clarified. 9/2014 Coding information clarified. 8/2014 Updated criteria for SRS qualification. Added facial feminization to non-cosmetic surgery section. Coding information clarified. Effective 8/27/2014. 6/2014 Updated Coding section with ICD10 procedure and diagnosis codes. Effective 10/2015. 4/2014 Language on benefit riders added. 4/2014 Coding information clarified.

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1/2/2010 New policy describing covered and non-covered services. Effective 1/2/2010.

Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

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26. Alberta Heritage Foundation for Medical Research (AHFMR). Vaginoplasty in male-female transsexuals and criteria for sex reassignment surgery. Technote TN 7. Edmonton, AB: AHFMR;
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38. Kääriäinen M, Salonen K, Helminen M, et al. Chest-wall contouring surgery in female-to-male transgender patients: A one-center retrospective analysis of applied surgical techniques and results. Scand J Surg. 2017 Mar;106(1):74-79.
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63. Nolan IT, Morrison SD, Arowojolu O, et al. The Role of Voice Therapy and Phonosurgery in Transgender Vocal Feminization. J Craniofac Surg. 2019;30(5):1368-1375. doi:10.1097/SCS.0000000000005132
64. Brown, S.K., Chang, J., Hu, S., Sivakumar, G., Sataluri, M., Goldberg, L. and Courey, M.S. (2020), Addition of Wendler Glottoplasty to Voice Therapy Improves Trans Female Voice Outcomes. The Laryngoscope. https://doi.org/10.1002/lary.29050
65. DeVore, E.K., Gadkaree, S.K., Richburg, K., Banaszak, E.M., Wang, T.V., Naunheim, M.R. and Shaye, D.A. (2020), Coverage for Gender‐Affirming Voice Surgery and Therapy for Transgender Individuals. The Laryngoscope. https://doi.org/10.1002/lary.28986
66. Song TE, Jiang N. Transgender Phonosurgery: A Systematic Review and Meta-analysis. Otolaryngology–Head and Neck Surgery. 2017;156(5):803-808. doi:10.1177/0194599817697050
67. Kanagalingam, J., Georgalas, C., Wood, G. R, et al. (2005). Cricothyroid approximation and subluxation in 21 male-to- female transsexuals. The Laryngoscope, 115(4), 611-618. doi:10.1097/01. mlg.0000161357.12826.33
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69. Brown, S.K., Chang, J., Hu, S., Sivakumar, G., Sataluri, M., Goldberg, L. and Courey, M.S. (2020), Addition of Wendler Glottoplasty to Voice Therapy Improves Trans Female Voice Outcomes. The Laryngoscope. https://doi.org/10.1002/lary.29050

    CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

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Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria (pp. 2-5) MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes Male to Female Surgery CPT codes Code Description 17380 Electrolysis epilation, each 30 minutes 19325 Breast augmentation with implant 19350 Nipple/areola reconstruction 19357 Tissue expander placement in breast reconstruction, including subsequent expansion(s) 19380 Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction) 53410 Urethroplasty, 1-stage reconstruction of male anterior urethra 53420 Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage 53425 Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage 54120 Amputation of penis; partial
54125 Amputation of penis; complete 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra 55970 Intersex surgery; male to female 56800 Plastic repair of introitus 56805 Clitoroplasty for intersex state 57291 Construction of artificial vagina; without graft
57292 Construction of artificial vagina; with graft 57335 Vaginoplasty for intersex state

Gender Affirming Facial Surgery Brow Reconstruction CPT codes Code Description 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 21175 Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (e.g., plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 Osteoplasty, facial bones; reduction 21299 Unlisted craniofacial and maxillofacial procedure 21499 Unlisted musculoskeletal procedure, head

Brow Lift CPT codes Code Description 67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

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Blepharoplasty CPT codes Code Description 15820 Blepharoplasty, lower eyelid 15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad 15822 Blepharoplasty, upper eyelid 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid

Rhinoplasty CPT codes Code Description 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 30420 Rhinoplasty, primary; including major septal repair Cheek Augmentation CPT codes Code Description 21270 Malar augmentation, prosthetic material 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 Osteoplasty, facial bones; reduction

Jaw Reconstruction CPT codes Code Description 21125 Augmentation, mandibular body or angle; prosthetic material 21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 Osteoplasty, facial bones; reduction 21299 Unlisted craniofacial and maxillofacial procedure 21499 Unlisted musculoskeletal procedure, head

Chin Reconstruction CPT codes Code Description 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) 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 Osteoplasty, facial bones; reduction 21299 Unlisted craniofacial and maxillofacial procedure 21499 Unlisted musculoskeletal procedure, head

Face Lift The following codes are covered when required as part of a medically necessary facial feminization procedure. CPT codes Code Description 15824 Rhytidectomy; forehead 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 15826 Rhytidectomy; glabellar frown lines 15828 Rhytidectomy; cheek, chin, and neck Liposuction

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The following codes are covered when required as part of a medically necessary facial feminization procedure. CPT codes Code Description 15876 Suction assisted lipectomy; head and neck Trachea Shave CPT codes Code Description 31599 Unlisted procedure, larynx Vocal Cord Surgery CPT codes Code Description 31599 Unlisted procedure, larynx

Female to Male Surgery
CPT codes: Code Description 15877 Suction assisted lipectomy; trunk 19303 Mastectomy, simple, complete 19316 Mastopexy 19318
Breast reduction
19350 Nipple/areola reconstruction 53430 Urethroplasty, reconstruction of female urethra 54660
Insertion testicular prosthesis 55175 Scrotoplasty; simple
55180 Scrotoplasty; complex 55980 Intersex surgery; female to male 56620 Vulvectomy; simple 56625 Vulvectomy; complete 56800 Plastic repair of introitus 56805 Clitoroplasty for intersex state 56810 Perineoplasty, repair of perineum, nonobstetrical 57110 Vaginectomy; complete removal of vaginal wall 57111 Vaginectomy; with removal of paravaginal tissue (radical vaginectomy)

HCPCS Codes HCPCS codes

Code Description Q4116 AlloDerm, per sq cm

The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT code above if above medical necessity criteria on pp. 1-2 are met: ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes Code Description F64.0 Transsexualism F64.1 Gender identity disorder in adolescence and adulthood F64.2 Gender identity disorder of childhood F64.8 Other identity disorders F64.9 Gender identity disorder, unspecified

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The above medical necessity criteria on pp. 2-7 MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: ICD-10 Procedure Codes Male to Female Surgery ICD-10-PCS procedure codes Code Description 0VTC0ZZ Resection of Bilateral Testes, Open Approach 0H0T0ZZ Alteration of Right Breast, Open Approach 0H0T3ZZ Alteration of Right Breast, Percutaneous Approach 0H0U0ZZ Alteration of Left Breast, Open Approach 0H0U3ZZ Alteration of Left Breast, Percutaneous Approach 0H0V07Z Alteration of Bilateral Breast with Autologous Tissue Substitute, Open Approach 0H0V0JZ Alteration of Bilateral Breast with Synthetic Substitute, Open Approach 0H0V0KZ Alteration of Bilateral Breast with Nonautologous Tissue Substitute, Open Approach 0H0V0ZZ Alteration of Bilateral Breast, Open Approach 0H0V37Z Alteration of Bilateral Breast with Autologous Tissue Substitute, Percutaneous Approach 0H0V3JZ Alteration of Bilateral Breast with Synthetic Substitute, Percutaneous Approach 0H0V3KZ Alteration of Bilateral Breast with Nonautologous Tissue Substitute, Percutaneous Approach 0H0V3ZZ Alteration of Bilateral Breast, Percutaneous Approach 0HDSXZZ Extraction of Hair, External Approach 0HMTXZZ Reattachment of Right Breast, External Approach 0HMUXZZ Reattachment of Left Breast, External Approach 0HMVXZZ Reattachment of Bilateral Breast, External Approach 0HMWXZZ Reattachment of Right Nipple, External Approach 0HMXXZZ Reattachment of Left Nipple, External Approach 0U5J0ZZ Destruction of Clitoris, Open Approach 0U5JXZZ Destruction of Clitoris, External Approach 0U9J00Z Drainage of Clitoris with Drainage Device, Open Approach 0U9J0ZZ Drainage of Clitoris, Open Approach 0U9JX0Z Drainage of Clitoris with Drainage Device, External Approach 0U9JXZZ Drainage of Clitoris, External Approach 0UBJ0ZX Excision of Clitoris, Open Approach, Diagnostic 0UBJ0ZZ Excision of Clitoris, Open Approach 0UBJXZX Excision of Clitoris, External Approach, Diagnostic 0UBJXZZ Excision of Clitoris, External Approach 0UCJ0ZZ Extirpation of Matter from Clitoris, Open Approach 0UCJXZZ Extirpation of Matter from Clitoris, External Approach 0UMJXZZ Reattachment of Clitoris, External Approach 0UNJ0ZZ Release Clitoris, Open Approach 0UNJXZZ Release Clitoris, External Approach 0UQG0ZZ Repair Vagina, Open Approach 0UQJ0ZZ Repair Clitoris, Open Approach 0UQJXZZ Repair Clitoris, External Approach 0UTJ0ZZ Resection of Clitoris, Open Approach 0UTJXZZ Resection of Clitoris, External Approach 0UUG07Z Supplement Vagina with Autologous Tissue Substitute, Open Approach 0UUG0JZ Supplement Vagina with Synthetic Substitute, Open Approach

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0UUG0KZ Supplement Vagina with Nonautologous Tissue Substitute, Open Approach 0UUG47Z Supplement Vagina with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0UUG4JZ Supplement Vagina with Synthetic Substitute, Percutaneous Endoscopic Approach 0UUG4KZ Supplement Vagina with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0UUG77Z Supplement Vagina with Autologous Tissue Substitute, Via Natural or Artificial Opening 0UUG7JZ Supplement Vagina with Synthetic Substitute, Via Natural or Artificial Opening 0UUG7KZ Supplement Vagina with Nonautologous Tissue Substitute, Via Natural or Artificial Opening 0UUG87Z Supplement Vagina with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0UUG8JZ Supplement Vagina with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0UUG8KZ Supplement Vagina with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0UUGX7Z Supplement Vagina with Autologous Tissue Substitute, External Approach 0UUGXJZ Supplement Vagina with Synthetic Substitute, External Approach 0UUGXKZ Supplement Vagina with Nonautologous Tissue Substitute, External Approach 0UUJ07Z Supplement Clitoris with Autologous Tissue Substitute, Open Approach 0UUJ0JZ Supplement Clitoris with Synthetic Substitute, Open Approach 0UUJ0KZ Supplement Clitoris with Nonautologous Tissue Substitute, Open Approach 0UUJX7Z Supplement Clitoris with Autologous Tissue Substitute, External Approach 0UUJXJZ Supplement Clitoris with Synthetic Substitute, External Approach 0UUJXKZ Supplement Clitoris with Nonautologous Tissue Substitute, External Approach 0VT90ZZ Resection of Right Testis, Open Approach 0VT94ZZ Resection of Right Testis, Percutaneous Endoscopic Approach 0VTB0ZZ Resection of Left Testis, Open Approach 0VTB4ZZ Resection of Left Testis, Percutaneous Endoscopic Approach 0VTC4ZZ Resection of Bilateral Testes, Percutaneous Endoscopic Approach 0VTS0ZZ Resection of Penis, Open Approach 0VTS4ZZ Resection of Penis, Percutaneous Endoscopic Approach 0VTSXZZ Resection of Penis, External Approach 0W4M070 Creation of Vagina in Male Perineum with Autologous Tissue Substitute, Open Approach 0W4M0J0 Creation of Vagina in Male Perineum with Synthetic Substitute, Open Approach 0W4M0K0 Creation of Vagina in Male Perineum with Nonautologous Tissue Substitute, Open Approach

Gender affirming Facial Surgery
ICD-10-PCS procedure codes Code Description 080N0ZZ Alteration of Right Upper Eyelid, Open Approach 080N3ZZ Alteration of Right Upper Eyelid, Percutaneous Approach 080NXZZ Alteration of Right Upper Eyelid, External Approach 080P0ZZ Alteration of Left Upper Eyelid, Open Approach 080P3ZZ Alteration of Left Upper Eyelid, Percutaneous Approach 080PXZZ Alteration of Left Upper Eyelid, External Approach 080Q0ZZ Alteration of Right Lower Eyelid, Open Approach 080Q3ZZ Alteration of Right Lower Eyelid, Percutaneous Approach 080QXZZ Alteration of Right Lower Eyelid, External Approach 080R0ZZ Alteration of Left Lower Eyelid, Open Approach

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080R3ZZ Alteration of Left Lower Eyelid, Percutaneous Approach 080RXZZ Alteration of Left Lower Eyelid, External Approach 090K0ZZ Alteration of Nose, Open Approach 090K3ZZ Alteration of Nose, Percutaneous Approach 090K4ZZ Alteration of Nose, Percutaneous Endoscopic Approach 090KXZZ Alteration of Nose, External Approach 09QM0ZZ Repair Nasal Septum, Open Approach 09QM3ZZ Repair Nasal Septum, Percutaneous Approach 09QM4ZZ Repair Nasal Septum, Percutaneous Endoscopic Approach 0J040ZZ Alteration of Anterior Neck Subcutaneous Tissue and Fascia, Open Approach 0J043ZZ Alteration of Anterior Neck Subcutaneous Tissue and Fascia, Percutaneous Approach 0J050ZZ Alteration of Posterior Neck Subcutaneous Tissue and Fascia, Open Approach 0J053ZZ Alteration of Posterior Neck Subcutaneous Tissue and Fascia, Percutaneous Approach 08SN0ZZ Reposition Right Upper Eyelid, Open Approach 08SN3ZZ Reposition Right Upper Eyelid, Percutaneous Approach 08SNXZZ Reposition Right Upper Eyelid, External Approach 08SP0ZZ Reposition Left Upper Eyelid, Open Approach 08SP3ZZ Reposition Left Upper Eyelid, Percutaneous Approach 08SPXZZ Reposition Left Upper Eyelid, External Approach 08SQ0ZZ Reposition Right Lower Eyelid, Open Approach 08SQ3ZZ Reposition Right Lower Eyelid, Percutaneous Approach 08SQXZZ Reposition Right Lower Eyelid, External Approach 08SR0ZZ Reposition Left Lower Eyelid, Open Approach 08SR3ZZ Reposition Left Lower Eyelid, Percutaneous Approach 08SRXZZ Reposition Left Lower Eyelid, External Approach 0KS10ZZ Reposition Facial Muscle, Open Approach 0KS14ZZ Reposition Facial Muscle, Percutaneous Endoscopic Approach 0NNC0ZZ Release Right Sphenoid Bone, Open Approach 0NNC3ZZ Release Right Sphenoid Bone, Percutaneous Approach 0NNC4ZZ Release Right Sphenoid Bone, Percutaneous Endoscopic Approach 0NNF0ZZ Release Right Ethmoid Bone, Open Approach 0NNF3ZZ Release Right Ethmoid Bone, Percutaneous Approach 0NNF4ZZ Release Right Ethmoid Bone, Percutaneous Endoscopic Approach 0NNG0ZZ Release Left Ethmoid Bone, Open Approach 0NNG3ZZ Release Left Ethmoid Bone, Percutaneous Approach 0NNG4ZZ Release Left Ethmoid Bone, Percutaneous Endoscopic Approach 0NNH0ZZ Release Right Lacrimal Bone, Open Approach 0NNH3ZZ Release Right Lacrimal Bone, Percutaneous Approach 0NNH4ZZ Release Right Lacrimal Bone, Percutaneous Endoscopic Approach 0NNJ0ZZ Release Left Lacrimal Bone, Open Approach 0NNJ3ZZ Release Left Lacrimal Bone, Percutaneous Approach 0NNJ4ZZ Release Left Lacrimal Bone, Percutaneous Endoscopic Approach 0NNK0ZZ Release Right Palatine Bone, Open Approach 0NNK3ZZ Release Right Palatine Bone, Percutaneous Approach 0NNK4ZZ Release Right Palatine Bone, Percutaneous Endoscopic Approach 0NNL0ZZ Release Left Palatine Bone, Open Approach 0NNL3ZZ Release Left Palatine Bone, Percutaneous Approach 0NNL4ZZ Release Left Palatine Bone, Percutaneous Endoscopic Approach 0NNM0ZZ Release Right Zygomatic Bone, Open Approach 0NNM3ZZ Release Right Zygomatic Bone, Percutaneous Approach 0NNM4ZZ Release Right Zygomatic Bone, Percutaneous Endoscopic Approach

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0NNN0ZZ Release Left Zygomatic Bone, Open Approach 0NNN3ZZ Release Left Zygomatic Bone, Percutaneous Approach 0NNN4ZZ Release Left Zygomatic Bone, Percutaneous Endoscopic Approach 0NNP0ZZ Release Right Orbit, Open Approach 0NNP3ZZ Release Right Orbit, Percutaneous Approach 0NNP4ZZ Release Right Orbit, Percutaneous Endoscopic Approach 0NNQ0ZZ Release Left Orbit, Open Approach 0NNQ3ZZ Release Left Orbit, Percutaneous Approach 0NNQ4ZZ Release Left Orbit, Percutaneous Endoscopic Approach 0NNR0ZZ Release Right Maxilla, Open Approach 0NNR3ZZ Release Right Maxilla, Percutaneous Approach 0NNR4ZZ Release Right Maxilla, Percutaneous Endoscopic Approach 0NNT0ZZ Release Right Mandible, Open Approach 0NNT3ZZ Release Right Mandible, Percutaneous Approach 0NNT4ZZ Release Right Mandible, Percutaneous Endoscopic Approach 0NNV0ZZ Release Left Mandible, Open Approach 0NNV3ZZ Release Left Mandible, Percutaneous Approach 0NNV4ZZ Release Left Mandible, Percutaneous Endoscopic Approach 0NQC0ZZ Repair Right Sphenoid Bone, Open Approach 0NQC3ZZ Repair Right Sphenoid Bone, Percutaneous Approach 0NQC4ZZ Repair Right Sphenoid Bone, Percutaneous Endoscopic Approach 0NQCXZZ Repair Right Sphenoid Bone, External Approach 0NQF0ZZ Repair Right Ethmoid Bone, Open Approach 0NQF3ZZ Repair Right Ethmoid Bone, Percutaneous Approach 0NQF4ZZ Repair Right Ethmoid Bone, Percutaneous Endoscopic Approach 0NQFXZZ Repair Right Ethmoid Bone, External Approach 0NQG0ZZ Repair Left Ethmoid Bone, Open Approach 0NQG3ZZ Repair Left Ethmoid Bone, Percutaneous Approach 0NQG4ZZ Repair Left Ethmoid Bone, Percutaneous Endoscopic Approach 0NQGXZZ Repair Left Ethmoid Bone, External Approach 0NQH0ZZ Repair Right Lacrimal Bone, Open Approach 0NQH3ZZ Repair Right Lacrimal Bone, Percutaneous Approach 0NQH4ZZ Repair Right Lacrimal Bone, Percutaneous Endoscopic Approach 0NQHXZZ Repair Right Lacrimal Bone, External Approach 0NQJ0ZZ Repair Left Lacrimal Bone, Open Approach 0NQJ3ZZ Repair Left Lacrimal Bone, Percutaneous Approach 0NQJ4ZZ Repair Left Lacrimal Bone, Percutaneous Endoscopic Approach 0NQJXZZ Repair Left Lacrimal Bone, External Approach 0NQK0ZZ Repair Right Palatine Bone, Open Approach 0NQK3ZZ Repair Right Palatine Bone, Percutaneous Approach 0NQK4ZZ Repair Right Palatine Bone, Percutaneous Endoscopic Approach 0NQKXZZ Repair Right Palatine Bone, External Approach 0NQL0ZZ Repair Left Palatine Bone, Open Approach 0NQL3ZZ Repair Left Palatine Bone, Percutaneous Approach 0NQL4ZZ Repair Left Palatine Bone, Percutaneous Endoscopic Approach 0NQLXZZ Repair Left Palatine Bone, External Approach 0NQM0ZZ Repair Right Zygomatic Bone, Open Approach 0NQM3ZZ Repair Right Zygomatic Bone, Percutaneous Approach 0NQM4ZZ Repair Right Zygomatic Bone, Percutaneous Endoscopic Approach 0NQMXZZ Repair Right Zygomatic Bone, External Approach 0NQN0ZZ Repair Left Zygomatic Bone, Open Approach

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0NQN3ZZ Repair Left Zygomatic Bone, Percutaneous Approach 0NQN4ZZ Repair Left Zygomatic Bone, Percutaneous Endoscopic Approach 0NQNXZZ Repair Left Zygomatic Bone, External Approach 0NQX0ZZ Repair Hyoid Bone, Open Approach 0NQX3ZZ Repair Hyoid Bone, Percutaneous Approach 0NQX4ZZ Repair Hyoid Bone, Percutaneous Endoscopic Approach 0NQXXZZ Repair Hyoid Bone, External Approach 0NRC07Z Replacement of Right Sphenoid Bone with Autologous Tissue Substitute, Open Approach 0NRC0JZ Replacement of Right Sphenoid Bone with Synthetic Substitute, Open Approach 0NRC0KZ Replacement of Right Sphenoid Bone with Nonautologous Tissue Substitute, Open Approach 0NRC37Z Replacement of Right Sphenoid Bone with Autologous Tissue Substitute, Percutaneous Approach 0NRC3JZ Replacement of Right Sphenoid Bone with Synthetic Substitute, Percutaneous Approach 0NRC3KZ Replacement of Right Sphenoid Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NRC47Z Replacement of Right Sphenoid Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRC4JZ Replacement of Right Sphenoid Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NRC4KZ Replacement of Right Sphenoid Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRF07Z Replacement of Right Ethmoid Bone with Autologous Tissue Substitute, Open Approach 0NRF0JZ Replacement of Right Ethmoid Bone with Synthetic Substitute, Open Approach 0NRF0KZ Replacement of Right Ethmoid Bone with Nonautologous Tissue Substitute, Open Approach 0NRF37Z Replacement of Right Ethmoid Bone with Autologous Tissue Substitute, Percutaneous Approach 0NRF3JZ Replacement of Right Ethmoid Bone with Synthetic Substitute, Percutaneous Approach 0NRF3KZ Replacement of Right Ethmoid Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NRF47Z Replacement of Right Ethmoid Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRF4JZ Replacement of Right Ethmoid Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NRF4KZ Replacement of Right Ethmoid Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRG07Z Replacement of Left Ethmoid Bone with Autologous Tissue Substitute, Open Approach 0NRG0JZ Replacement of Left Ethmoid Bone with Synthetic Substitute, Open Approach 0NRG0KZ Replacement of Left Ethmoid Bone with Nonautologous Tissue Substitute, Open Approach 0NRG37Z Replacement of Left Ethmoid Bone with Autologous Tissue Substitute, Percutaneous Approach 0NRG3JZ Replacement of Left Ethmoid Bone with Synthetic Substitute, Percutaneous Approach 0NRG3KZ Replacement of Left Ethmoid Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NRG47Z Replacement of Left Ethmoid Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRG4JZ Replacement of Left Ethmoid Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NRG4KZ Replacement of Left Ethmoid Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach

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0NRH07Z Replacement of Right Lacrimal Bone with Autologous Tissue Substitute, Open Approach 0NRH0JZ Replacement of Right Lacrimal Bone with Synthetic Substitute, Open Approach 0NRH0KZ Replacement of Right Lacrimal Bone with Nonautologous Tissue Substitute, Open Approach 0NRH37Z Replacement of Right Lacrimal Bone with Autologous Tissue Substitute, Percutaneous Approach 0NRH3JZ Replacement of Right Lacrimal Bone with Synthetic Substitute, Percutaneous Approach 0NRH3KZ Replacement of Right Lacrimal Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NRH47Z Replacement of Right Lacrimal Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRH4JZ Replacement of Right Lacrimal Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NRH4KZ Replacement of Right Lacrimal Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRJ07Z Replacement of Left Lacrimal Bone with Autologous Tissue Substitute, Open Approach 0NRJ0JZ Replacement of Left Lacrimal Bone with Synthetic Substitute, Open Approach 0NRJ0KZ Replacement of Left Lacrimal Bone with Nonautologous Tissue Substitute, Open Approach 0NRJ37Z Replacement of Left Lacrimal Bone with Autologous Tissue Substitute, Percutaneous Approach 0NRJ3JZ Replacement of Left Lacrimal Bone with Synthetic Substitute, Percutaneous Approach 0NRJ3KZ Replacement of Left Lacrimal Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NRJ47Z Replacement of Left Lacrimal Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRJ4JZ Replacement of Left Lacrimal Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NRJ4KZ Replacement of Left Lacrimal Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRK07Z Replacement of Right Palatine Bone with Autologous Tissue Substitute, Open Approach 0NRK0JZ Replacement of Right Palatine Bone with Synthetic Substitute, Open Approach 0NRK0KZ Replacement of Right Palatine Bone with Nonautologous Tissue Substitute, Open Approach 0NRK37Z Replacement of Right Palatine Bone with Autologous Tissue Substitute, Percutaneous Approach 0NRK3JZ Replacement of Right Palatine Bone with Synthetic Substitute, Percutaneous Approach 0NRK3KZ Replacement of Right Palatine Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NRK47Z Replacement of Right Palatine Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRK4JZ Replacement of Right Palatine Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NRK4KZ Replacement of Right Palatine Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRL07Z Replacement of Left Palatine Bone with Autologous Tissue Substitute, Open Approach 0NRL0JZ Replacement of Left Palatine Bone with Synthetic Substitute, Open Approach 0NRL0KZ Replacement of Left Palatine Bone with Nonautologous Tissue Substitute, Open Approach 0NRL37Z Replacement of Left Palatine Bone with Autologous Tissue Substitute, Percutaneous Approach 0NRL3JZ Replacement of Left Palatine Bone with Synthetic Substitute, Percutaneous Approach 0NRL3KZ Replacement of Left Palatine Bone with Nonautologous Tissue Substitute, Percutaneous Approach

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0NRL47Z Replacement of Left Palatine Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRL4JZ Replacement of Left Palatine Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NRL4KZ Replacement of Left Palatine Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRM07Z Replacement of Right Zygomatic Bone with Autologous Tissue Substitute, Open Approach 0NRM0JZ Replacement of Right Zygomatic Bone with Synthetic Substitute, Open Approach 0NRM0KZ Replacement of Right Zygomatic Bone with Nonautologous Tissue Substitute, Open Approach 0NRM37Z Replacement of Right Zygomatic Bone with Autologous Tissue Substitute, Percutaneous Approach 0NRM3JZ Replacement of Right Zygomatic Bone with Synthetic Substitute, Percutaneous Approach 0NRM3KZ Replacement of Right Zygomatic Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NRM47Z Replacement of Right Zygomatic Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRM4JZ Replacement of Right Zygomatic Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NRM4KZ Replacement of Right Zygomatic Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRN07Z Replacement of Left Zygomatic Bone with Autologous Tissue Substitute, Open Approach 0NRN0JZ Replacement of Left Zygomatic Bone with Synthetic Substitute, Open Approach 0NRN0KZ Replacement of Left Zygomatic Bone with Nonautologous Tissue Substitute, Open Approach 0NRN37Z Replacement of Left Zygomatic Bone with Autologous Tissue Substitute, Percutaneous Approach 0NRN3JZ Replacement of Left Zygomatic Bone with Synthetic Substitute, Percutaneous Approach 0NRN3KZ Replacement of Left Zygomatic Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NRN47Z Replacement of Left Zygomatic Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRN4JZ Replacement of Left Zygomatic Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NRN4KZ Replacement of Left Zygomatic Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRP0KZ Replacement of Right Orbit with Nonautologous Tissue Substitute, Open Approach 0NRP3KZ Replacement of Right Orbit with Nonautologous Tissue Substitute, Percutaneous Approach 0NRP4KZ Replacement of Right Orbit with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRQ0KZ Replacement of Left Orbit with Nonautologous Tissue Substitute, Open Approach 0NRQ3KZ Replacement of Left Orbit with Nonautologous Tissue Substitute, Percutaneous Approach 0NRQ4KZ Replacement of Left Orbit with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRR07Z Replacement of Right Maxilla with Autologous Tissue Substitute, Open Approach 0NRR0JZ Replacement of Right Maxilla with Synthetic Substitute, Open Approach 0NRR0KZ Replacement of Right Maxilla with Nonautologous Tissue Substitute, Open Approach 0NRR37Z Replacement of Right Maxilla with Autologous Tissue Substitute, Percutaneous Approach 0NRR3JZ Replacement of Right Maxilla with Synthetic Substitute, Percutaneous Approach

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0NRR3KZ Replacement of Right Maxilla with Nonautologous Tissue Substitute, Percutaneous Approach 0NRR47Z Replacement of Right Maxilla with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRR4JZ Replacement of Right Maxilla with Synthetic Substitute, Percutaneous Endoscopic Approach 0NRR4KZ Replacement of Right Maxilla with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRX07Z Replacement of Hyoid Bone with Autologous Tissue Substitute, Open Approach 0NRX0JZ Replacement of Hyoid Bone with Synthetic Substitute, Open Approach 0NRX0KZ Replacement of Hyoid Bone with Nonautologous Tissue Substitute, Open Approach 0NRX37Z Replacement of Hyoid Bone with Autologous Tissue Substitute, Percutaneous Approach 0NRX3JZ Replacement of Hyoid Bone with Synthetic Substitute, Percutaneous Approach 0NRX3KZ Replacement of Hyoid Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NRX47Z Replacement of Hyoid Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NRX4JZ Replacement of Hyoid Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NRX4KZ Replacement of Hyoid Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUC07Z Supplement Right Sphenoid Bone with Autologous Tissue Substitute, Open Approach 0NUC0JZ Supplement Right Sphenoid Bone with Synthetic Substitute, Open Approach 0NUC0KZ Supplement Right Sphenoid Bone with Nonautologous Tissue Substitute, Open Approach 0NUC37Z Supplement Right Sphenoid Bone with Autologous Tissue Substitute, Percutaneous Approach 0NUC3JZ Supplement Right Sphenoid Bone with Synthetic Substitute, Percutaneous Approach 0NUC3KZ Supplement Right Sphenoid Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NUC47Z Supplement Right Sphenoid Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUC4JZ Supplement Right Sphenoid Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUC4KZ Supplement Right Sphenoid Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUF07Z Supplement Right Ethmoid Bone with Autologous Tissue Substitute, Open Approach 0NUF0JZ Supplement Right Ethmoid Bone with Synthetic Substitute, Open Approach 0NUF0KZ Supplement Right Ethmoid Bone with Nonautologous Tissue Substitute, Open Approach 0NUF37Z Supplement Right Ethmoid Bone with Autologous Tissue Substitute, Percutaneous Approach 0NUF3JZ Supplement Right Ethmoid Bone with Synthetic Substitute, Percutaneous Approach 0NUF3KZ Supplement Right Ethmoid Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NUF47Z Supplement Right Ethmoid Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUF4JZ Supplement Right Ethmoid Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUF4KZ Supplement Right Ethmoid Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUG07Z Supplement Left Ethmoid Bone with Autologous Tissue Substitute, Open Approach 0NUG0JZ Supplement Left Ethmoid Bone with Synthetic Substitute, Open Approach 0NUG0KZ Supplement Left Ethmoid Bone with Nonautologous Tissue Substitute, Open Approach

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0NUG37Z Supplement Left Ethmoid Bone with Autologous Tissue Substitute, Percutaneous Approach 0NUG3JZ Supplement Left Ethmoid Bone with Synthetic Substitute, Percutaneous Approach 0NUG3KZ Supplement Left Ethmoid Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NUG47Z Supplement Left Ethmoid Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUG4JZ Supplement Left Ethmoid Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUG4KZ Supplement Left Ethmoid Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUH07Z Supplement Right Lacrimal Bone with Autologous Tissue Substitute, Open Approach 0NUH0JZ Supplement Right Lacrimal Bone with Synthetic Substitute, Open Approach 0NUH0KZ Supplement Right Lacrimal Bone with Nonautologous Tissue Substitute, Open Approach 0NUH37Z Supplement Right Lacrimal Bone with Autologous Tissue Substitute, Percutaneous Approach 0NUH3JZ Supplement Right Lacrimal Bone with Synthetic Substitute, Percutaneous Approach 0NUH3KZ Supplement Right Lacrimal Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NUH47Z Supplement Right Lacrimal Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUH4JZ Supplement Right Lacrimal Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUH4KZ Supplement Right Lacrimal Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUJ07Z Supplement Left Lacrimal Bone with Autologous Tissue Substitute, Open Approach 0NUJ0JZ Supplement Left Lacrimal Bone with Synthetic Substitute, Open Approach 0NUJ0KZ Supplement Left Lacrimal Bone with Nonautologous Tissue Substitute, Open Approach 0NUJ37Z Supplement Left Lacrimal Bone with Autologous Tissue Substitute, Percutaneous Approach 0NUJ3JZ Supplement Left Lacrimal Bone with Synthetic Substitute, Percutaneous Approach 0NUJ3KZ Supplement Left Lacrimal Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NUJ47Z Supplement Left Lacrimal Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUJ4JZ Supplement Left Lacrimal Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUJ4KZ Supplement Left Lacrimal Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUK07Z Supplement Right Palatine Bone with Autologous Tissue Substitute, Open Approach 0NUK0JZ Supplement Right Palatine Bone with Synthetic Substitute, Open Approach 0NUK0KZ Supplement Right Palatine Bone with Nonautologous Tissue Substitute, Open Approach 0NUK37Z Supplement Right Palatine Bone with Autologous Tissue Substitute, Percutaneous Approach 0NUK3JZ Supplement Right Palatine Bone with Synthetic Substitute, Percutaneous Approach 0NUK3KZ Supplement Right Palatine Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NUK47Z Supplement Right Palatine Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUK4JZ Supplement Right Palatine Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUK4KZ Supplement Right Palatine Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUL07Z Supplement Left Palatine Bone with Autologous Tissue Substitute, Open Approach

25

0NUL0JZ Supplement Left Palatine Bone with Synthetic Substitute, Open Approach 0NUL0KZ Supplement Left Palatine Bone with Nonautologous Tissue Substitute, Open Approach 0NUL37Z Supplement Left Palatine Bone with Autologous Tissue Substitute, Percutaneous Approach 0NUL3JZ Supplement Left Palatine Bone with Synthetic Substitute, Percutaneous Approach 0NUL3KZ Supplement Left Palatine Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NUL47Z Supplement Left Palatine Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUL4JZ Supplement Left Palatine Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUL4KZ Supplement Left Palatine Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUM07Z Supplement Right Zygomatic Bone with Autologous Tissue Substitute, Open Approach 0NUM0JZ Supplement Right Zygomatic Bone with Synthetic Substitute, Open Approach 0NUM0KZ Supplement Right Zygomatic Bone with Nonautologous Tissue Substitute, Open Approach 0NUM37Z Supplement Right Zygomatic Bone with Autologous Tissue Substitute, Percutaneous Approach 0NUM3JZ Supplement Right Zygomatic Bone with Synthetic Substitute, Percutaneous Approach 0NUM3KZ Supplement Right Zygomatic Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NUM47Z Supplement Right Zygomatic Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUM4JZ Supplement Right Zygomatic Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUM4KZ Supplement Right Zygomatic Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUN07Z Supplement Left Zygomatic Bone with Autologous Tissue Substitute, Open Approach 0NUN0JZ Supplement Left Zygomatic Bone with Synthetic Substitute, Open Approach 0NUN0KZ Supplement Left Zygomatic Bone with Nonautologous Tissue Substitute, Open Approach 0NUN37Z Supplement Left Zygomatic Bone with Autologous Tissue Substitute, Percutaneous Approach 0NUN3JZ Supplement Left Zygomatic Bone with Synthetic Substitute, Percutaneous Approach 0NUN3KZ Supplement Left Zygomatic Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NUN47Z Supplement Left Zygomatic Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUN4JZ Supplement Left Zygomatic Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUN4KZ Supplement Left Zygomatic Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUP07Z Supplement Right Orbit with Autologous Tissue Substitute, Open Approach 0NUP0KZ Supplement Right Orbit with Nonautologous Tissue Substitute, Open Approach 0NUP37Z Supplement Right Orbit with Autologous Tissue Substitute, Percutaneous Approach 0NUP3KZ Supplement Right Orbit with Nonautologous Tissue Substitute, Percutaneous Approach 0NUP47Z Supplement Right Orbit with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUP4KZ Supplement Right Orbit with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUQ07Z Supplement Left Orbit with Autologous Tissue Substitute, Open Approach 0NUQ0KZ Supplement Left Orbit with Nonautologous Tissue Substitute, Open Approach 0NUQ37Z Supplement Left Orbit with Autologous Tissue Substitute, Percutaneous Approach

26

0NUQ3KZ Supplement Left Orbit with Nonautologous Tissue Substitute, Percutaneous Approach 0NUQ47Z Supplement Left Orbit with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUQ4KZ Supplement Left Orbit with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUR07Z Supplement Right Maxilla with Autologous Tissue Substitute, Open Approach 0NUR0JZ Supplement Right Maxilla with Synthetic Substitute, Open Approach 0NUR0KZ Supplement Right Maxilla with Nonautologous Tissue Substitute, Open Approach 0NUR37Z Supplement Right Maxilla with Autologous Tissue Substitute, Percutaneous Approach 0NUR3JZ Supplement Right Maxilla with Synthetic Substitute, Percutaneous Approach 0NUR3KZ Supplement Right Maxilla with Nonautologous Tissue Substitute, Percutaneous Approach 0NUR47Z Supplement Right Maxilla with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUR4JZ Supplement Right Maxilla with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUR4KZ Supplement Right Maxilla with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUX07Z Supplement Hyoid Bone with Autologous Tissue Substitute, Open Approach 0NUX0JZ Supplement Hyoid Bone with Synthetic Substitute, Open Approach 0NUX0KZ Supplement Hyoid Bone with Nonautologous Tissue Substitute, Open Approach 0NUX37Z Supplement Hyoid Bone with Autologous Tissue Substitute, Percutaneous Approach 0NUX3JZ Supplement Hyoid Bone with Synthetic Substitute, Percutaneous Approach 0NUX3KZ Supplement Hyoid Bone with Nonautologous Tissue Substitute, Percutaneous Approach 0NUX47Z Supplement Hyoid Bone with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0NUX4JZ Supplement Hyoid Bone with Synthetic Substitute, Percutaneous Endoscopic Approach 0NUX4KZ Supplement Hyoid Bone with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0RNC0ZZ Release Right Temporomandibular Joint, Open Approach 0RNC3ZZ Release Right Temporomandibular Joint, Percutaneous Approach 0RNC4ZZ Release Right Temporomandibular Joint, Percutaneous Endoscopic Approach 0RND0ZZ Release Left Temporomandibular Joint, Open Approach 0RND3ZZ Release Left Temporomandibular Joint, Percutaneous Approach 0RND4ZZ Release Left Temporomandibular Joint, Percutaneous Endoscopic Approach 0W0407Z Alteration of Upper Jaw with Autologous Tissue Substitute, Open Approach 0W040JZ Alteration of Upper Jaw with Synthetic Substitute, Open Approach 0W040KZ Alteration of Upper Jaw with Nonautologous Tissue Substitute, Open Approach 0W040ZZ Alteration of Upper Jaw, Open Approach 0W0437Z Alteration of Upper Jaw with Autologous Tissue Substitute, Percutaneous Approach 0W043JZ Alteration of Upper Jaw with Synthetic Substitute, Percutaneous Approach 0W043KZ Alteration of Upper Jaw with Nonautologous Tissue Substitute, Percutaneous Approach 0W043ZZ Alteration of Upper Jaw, Percutaneous Approach 0W0447Z Alteration of Upper Jaw with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0W044JZ Alteration of Upper Jaw with Synthetic Substitute, Percutaneous Endoscopic Approach 0W044KZ Alteration of Upper Jaw with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0W044ZZ Alteration of Upper Jaw, Percutaneous Endoscopic Approach 0W0507Z Alteration of Lower Jaw with Autologous Tissue Substitute, Open Approach 0W050JZ Alteration of Lower Jaw with Synthetic Substitute, Open Approach 0W050KZ Alteration of Lower Jaw with Nonautologous Tissue Substitute, Open Approach 0W050ZZ Alteration of Lower Jaw, Open Approach

27

0W0537Z Alteration of Lower Jaw with Autologous Tissue Substitute, Percutaneous Approach 0W053JZ Alteration of Lower Jaw with Synthetic Substitute, Percutaneous Approach 0W053KZ Alteration of Lower Jaw with Nonautologous Tissue Substitute, Percutaneous Approach 0W053ZZ Alteration of Lower Jaw, Percutaneous Approach 0W0547Z Alteration of Lower Jaw with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0W054JZ Alteration of Lower Jaw with Synthetic Substitute, Percutaneous Endoscopic Approach 0W054KZ Alteration of Lower Jaw with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0W054ZZ Alteration of Lower Jaw, Percutaneous Endoscopic Approach 0W020ZZ Alteration of Face, Open Approach 0W0207Z Alteration of Face with Autologous Tissue Substitute, Open Approach 0W020JZ Alteration of Face with Synthetic Substitute, Open Approach 0W020KZ Alteration of Face with Nonautologous Tissue Substitute, Open Approach 0W023ZZ Alteration of Face, Percutaneous Approach 0W0247Z Alteration of Face with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0W024JZ Alteration of Face with Synthetic Substitute, Percutaneous Endoscopic Approach 0W024KZ Alteration of Face with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0W024ZZ Alteration of Face, Percutaneous Endoscopic Approach 0NS104Z Reposition Right Frontal Bone with Internal Fixation Device, Open Approach

Female to Male Surgery ICD-10-PCS procedure codes Code Description 0VTC0ZZ Resection of Bilateral Testes, Open Approach 0H0T0ZZ Alteration of Right Breast, Open Approach 0H0T3ZZ Alteration of Right Breast, Percutaneous Approach 0H0U0ZZ Alteration of Left Breast, Open Approach 0H0U3ZZ Alteration of Left Breast, Percutaneous Approach 0H0V07Z Alteration of Bilateral Breast with Autologous Tissue Substitute, Open Approach 0H0V0JZ Alteration of Bilateral Breast with Synthetic Substitute, Open Approach 0H0V0KZ Alteration of Bilateral Breast with Nonautologous Tissue Substitute, Open Approach 0H0V0ZZ Alteration of Bilateral Breast, Open Approach 0H0V37Z Alteration of Bilateral Breast with Autologous Tissue Substitute, Percutaneous Approach 0H0V3JZ Alteration of Bilateral Breast with Synthetic Substitute, Percutaneous Approach 0H0V3KZ Alteration of Bilateral Breast with Nonautologous Tissue Substitute, Percutaneous Approach 0H0V3ZZ Alteration of Bilateral Breast, Percutaneous Approach 0HDSXZZ Extraction of Hair, External Approach 0HMTXZZ Reattachment of Right Breast, External Approach 0HMUXZZ Reattachment of Left Breast, External Approach 0HMVXZZ Reattachment of Bilateral Breast, External Approach 0HMWXZZ Reattachment of Right Nipple, External Approach 0HMXXZZ Reattachment of Left Nipple, External Approach 0HNT0ZZ Release Right Breast, Open Approach 0HNT3ZZ Release Right Breast, Percutaneous Approach 0HNT7ZZ Release Right Breast, Via Natural or Artificial Opening 0HNT8ZZ Release Right Breast, Via Natural or Artificial Opening Endoscopic 0HNTXZZ Release Right Breast, External Approach

28

0HNU0ZZ Release Left Breast, Open Approach 0HNU3ZZ Release Left Breast, Percutaneous Approach 0HNU7ZZ Release Left Breast, Via Natural or Artificial Opening 0HNU8ZZ Release Left Breast, Via Natural or Artificial Opening Endoscopic 0HNV0ZZ Release Bilateral Breast, Open Approach 0HNV3ZZ Release Bilateral Breast, Percutaneous Approach 0HNV7ZZ Release Bilateral Breast, Via Natural or Artificial Opening 0HNV8ZZ Release Bilateral Breast, Via Natural or Artificial Opening Endoscopic 0HNVXZZ Release Bilateral Breast, External Approach 0HNW0ZZ Release Right Nipple, Open Approach 0HNW3ZZ Release Right Nipple, Percutaneous Approach 0HNW7ZZ Release Right Nipple, Via Natural or Artificial Opening 0HNW8ZZ Release Right Nipple, Via Natural or Artificial Opening Endoscopic 0HNWXZZ Release Right Nipple, External Approach 0HNX0ZZ Release Left Nipple, Open Approach 0HNX3ZZ Release Left Nipple, Percutaneous Approach 0HNX7ZZ Release Left Nipple, Via Natural or Artificial Opening 0HNX8ZZ Release Left Nipple, Via Natural or Artificial Opening Endoscopic 0HNXXZZ Release Left Nipple, External Approach 0HQT0ZZ Repair Right Breast, Open Approach 0HQT3ZZ Repair Right Breast, Percutaneous Approach 0HQT7ZZ Repair Right Breast, Via Natural or Artificial Opening 0HQT8ZZ Repair Right Breast, Via Natural or Artificial Opening Endoscopic 0HQU0ZZ Repair Left Breast, Open Approach 0HQU3ZZ Repair Left Breast, Percutaneous Approach 0HQU7ZZ Repair Left Breast, Via Natural or Artificial Opening 0HQU8ZZ Repair Left Breast, Via Natural or Artificial Opening Endoscopic 0HQV0ZZ Repair Bilateral Breast, Open Approach 0HQV3ZZ Repair Bilateral Breast, Percutaneous Approach 0HQV7ZZ Repair Bilateral Breast, Via Natural or Artificial Opening 0HQV8ZZ Repair Bilateral Breast, Via Natural or Artificial Opening Endoscopic 0HQW0ZZ Repair Right Nipple, Open Approach 0HQW3ZZ Repair Right Nipple, Percutaneous Approach 0HQW7ZZ Repair Right Nipple, Via Natural or Artificial Opening 0HQW8ZZ Repair Right Nipple, Via Natural or Artificial Opening Endoscopic 0HQWXZZ Repair Right Nipple, External Approach 0HQX0ZZ Repair Left Nipple, Open Approach 0HQX3ZZ Repair Left Nipple, Percutaneous Approach 0HQX7ZZ Repair Left Nipple, Via Natural or Artificial Opening 0HQX8ZZ Repair Left Nipple, Via Natural or Artificial Opening Endoscopic 0HQXXZZ Repair Left Nipple, External Approach 0HQY0ZZ Repair Supernumerary Breast, Open Approach 0HQY3ZZ Repair Supernumerary Breast, Percutaneous Approach 0HQY7ZZ Repair Supernumerary Breast, Via Natural or Artificial Opening 0HQY8ZZ Repair Supernumerary Breast, Via Natural or Artificial Opening Endoscopic 0HRT07Z Replacement of Right Breast with Autologous Tissue Substitute, Open Approach 0HRT0KZ Replacement of Right Breast with Nonautologous Tissue Substitute, Open Approach 0HRT37Z Replacement of Right Breast with Autologous Tissue Substitute, Percutaneous Approach 0HRT3KZ Replacement of Right Breast with Nonautologous Tissue Substitute, Percutaneous Approach 0HRU07Z Replacement of Left Breast with Autologous Tissue Substitute, Open Approach

29

0HRU0KZ Replacement of Left Breast with Nonautologous Tissue Substitute, Open Approach 0HRU37Z Replacement of Left Breast with Autologous Tissue Substitute, Percutaneous Approach 0HRU3KZ Replacement of Left Breast with Nonautologous Tissue Substitute, Percutaneous Approach 0HRV07Z Replacement of Bilateral Breast with Autologous Tissue Substitute, Open Approach 0HRV0KZ Replacement of Bilateral Breast with Nonautologous Tissue Substitute, Open Approach 0HRV37Z Replacement of Bilateral Breast with Autologous Tissue Substitute, Percutaneous Approach 0HRV3KZ Replacement of Bilateral Breast with Nonautologous Tissue Substitute, Percutaneous Approach 0HRW07Z Replacement of Right Nipple with Autologous Tissue Substitute, Open Approach 0HRW0JZ Replacement of Right Nipple with Synthetic Substitute, Open Approach 0HRW0KZ Replacement of Right Nipple with Nonautologous Tissue Substitute, Open Approach 0HRW37Z Replacement of Right Nipple with Autologous Tissue Substitute, Percutaneous Approach 0HRW3JZ Replacement of Right Nipple with Synthetic Substitute, Percutaneous Approach 0HRW3KZ Replacement of Right Nipple with Nonautologous Tissue Substitute, Percutaneous Approach 0HRWX7Z Replacement of Right Nipple with Autologous Tissue Substitute, External Approach 0HRWXJZ Replacement of Right Nipple with Synthetic Substitute, External Approach 0HRWXKZ Replacement of Right Nipple with Nonautologous Tissue Substitute, External Approach 0HRX07Z Replacement of Left Nipple with Autologous Tissue Substitute, Open Approach 0HRX0JZ Replacement of Left Nipple with Synthetic Substitute, Open Approach 0HRX0KZ Replacement of Left Nipple with Nonautologous Tissue Substitute, Open Approach 0HRX37Z Replacement of Left Nipple with Autologous Tissue Substitute, Percutaneous Approach 0HRX3JZ Replacement of Left Nipple with Synthetic Substitute, Percutaneous Approach 0HRX3KZ Replacement of Left Nipple with Nonautologous Tissue Substitute, Percutaneous Approach 0HRXX7Z Replacement of Left Nipple with Autologous Tissue Substitute, External Approach 0HRXXJZ Replacement of Left Nipple with Synthetic Substitute, External Approach 0HRXXKZ Replacement of Left Nipple with Nonautologous Tissue Substitute, External Approach 0HUT07Z Supplement Right Breast with Autologous Tissue Substitute, Open Approach 0HUT0JZ Supplement Right Breast with Synthetic Substitute, Open Approach 0HUT0KZ Supplement Right Breast with Nonautologous Tissue Substitute, Open Approach 0HUT37Z Supplement Right Breast with Autologous Tissue Substitute, Percutaneous Approach 0HUT3JZ Supplement Right Breast with Synthetic Substitute, Percutaneous Approach 0HUT3KZ Supplement Right Breast with Nonautologous Tissue Substitute, Percutaneous Approach 0HUT77Z Supplement Right Breast with Autologous Tissue Substitute, Via Natural or Artificial Opening 0HUT7JZ Supplement Right Breast with Synthetic Substitute, Via Natural or Artificial Opening 0HUT7KZ Supplement Right Breast with Nonautologous Tissue Substitute, Via Natural or Artificial Opening 0HUT87Z Supplement Right Breast with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0HUT8JZ Supplement Right Breast with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0HUT8KZ Supplement Right Breast with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0HUU07Z Supplement Left Breast with Autologous Tissue Substitute, Open Approach 0HUU0JZ Supplement Left Breast with Synthetic Substitute, Open Approach 0HUU0KZ Supplement Left Breast with Nonautologous Tissue Substitute, Open Approach 0HUU37Z Supplement Left Breast with Autologous Tissue Substitute, Percutaneous Approach 0HUU3JZ Supplement Left Breast with Synthetic Substitute, Percutaneous Approach

30

0HUU3KZ Supplement Left Breast with Nonautologous Tissue Substitute, Percutaneous Approach 0HUU77Z Supplement Left Breast with Autologous Tissue Substitute, Via Natural or Artificial Opening 0HUU7JZ Supplement Left Breast with Synthetic Substitute, Via Natural or Artificial Opening 0HUU7KZ Supplement Left Breast with Nonautologous Tissue Substitute, Via Natural or Artificial Opening 0HUU87Z Supplement Left Breast with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0HUU8JZ Supplement Left Breast with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0HUU8KZ Supplement Left Breast with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0HUV07Z Supplement Bilateral Breast with Autologous Tissue Substitute, Open Approach 0HUV0JZ Supplement Bilateral Breast with Synthetic Substitute, Open Approach 0HUV0KZ Supplement Bilateral Breast with Nonautologous Tissue Substitute, Open Approach 0HUV37Z Supplement Bilateral Breast with Autologous Tissue Substitute, Percutaneous Approach 0HUV3JZ Supplement Bilateral Breast with Synthetic Substitute, Percutaneous Approach 0HUV3KZ Supplement Bilateral Breast with Nonautologous Tissue Substitute, Percutaneous Approach 0HUV77Z Supplement Bilateral Breast with Autologous Tissue Substitute, Via Natural or Artificial Opening 0HUV7JZ Supplement Bilateral Breast with Synthetic Substitute, Via Natural or Artificial Opening 0HUV7KZ Supplement Bilateral Breast with Nonautologous Tissue Substitute, Via Natural or Artificial Opening 0HUV87Z Supplement Bilateral Breast with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0HUV8JZ Supplement Bilateral Breast with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0HUV8KZ Supplement Bilateral Breast with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0HUW07Z Supplement Right Nipple with Autologous Tissue Substitute, Open Approach 0HUW0JZ Supplement Right Nipple with Synthetic Substitute, Open Approach 0HUW0KZ Supplement Right Nipple with Nonautologous Tissue Substitute, Open Approach 0HUW37Z Supplement Right Nipple with Autologous Tissue Substitute, Percutaneous Approach 0HUW3JZ Supplement Right Nipple with Synthetic Substitute, Percutaneous Approach 0HUW3KZ Supplement Right Nipple with Nonautologous Tissue Substitute, Percutaneous Approach 0HUW77Z Supplement Right Nipple with Autologous Tissue Substitute, Via Natural or Artificial Opening 0HUW7JZ Supplement Right Nipple with Synthetic Substitute, Via Natural or Artificial Opening 0HUW7KZ Supplement Right Nipple with Nonautologous Tissue Substitute, Via Natural or Artificial Opening 0HUW87Z Supplement Right Nipple with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0HUW8JZ Supplement Right Nipple with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0HUW8KZ Supplement Right Nipple with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0HUWX7Z Supplement Right Nipple with Autologous Tissue Substitute, External Approach 0HUWXJZ Supplement Right Nipple with Synthetic Substitute, External Approach 0HUWXKZ Supplement Right Nipple with Nonautologous Tissue Substitute, External Approach 0HUX07Z Supplement Left Nipple with Autologous Tissue Substitute, Open Approach 0HUX0JZ Supplement Left Nipple with Synthetic Substitute, Open Approach 0HUX0KZ Supplement Left Nipple with Nonautologous Tissue Substitute, Open Approach

31

0HUX37Z Supplement Left Nipple with Autologous Tissue Substitute, Percutaneous Approach 0HUX3JZ Supplement Left Nipple with Synthetic Substitute, Percutaneous Approach 0HUX3KZ Supplement Left Nipple with Nonautologous Tissue Substitute, Percutaneous Approach 0HUX77Z Supplement Left Nipple with Autologous Tissue Substitute, Via Natural or Artificial Opening 0HUX7JZ Supplement Left Nipple with Synthetic Substitute, Via Natural or Artificial Opening 0HUX7KZ Supplement Left Nipple with Nonautologous Tissue Substitute, Via Natural or Artificial Opening 0HUX87Z Supplement Left Nipple with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0HUX8JZ Supplement Left Nipple with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0HUX8KZ Supplement Left Nipple with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0HUXX7Z Supplement Left Nipple with Autologous Tissue Substitute, External Approach 0HUXXJZ Supplement Left Nipple with Synthetic Substitute, External Approach 0HUXXKZ Supplement Left Nipple with Nonautologous Tissue Substitute, External Approach 0U5J0ZZ Destruction of Clitoris, Open Approach 0U5JXZZ Destruction of Clitoris, External Approach 0U9J00Z Drainage of Clitoris with Drainage Device, Open Approach 0U9J0ZZ Drainage of Clitoris, Open Approach 0U9JX0Z Drainage of Clitoris with Drainage Device, External Approach 0U9JXZZ Drainage of Clitoris, External Approach 0UBJ0ZX Excision of Clitoris, Open Approach, Diagnostic 0UBJ0ZZ Excision of Clitoris, Open Approach 0UBJXZX Excision of Clitoris, External Approach, Diagnostic 0UBJXZZ Excision of Clitoris, External Approach 0UCJ0ZZ Extirpation of Matter from Clitoris, Open Approach 0UCJXZZ Extirpation of Matter from Clitoris, External Approach 0UMJXZZ Reattachment of Clitoris, External Approach 0UNJ0ZZ Release Clitoris, Open Approach 0UNJXZZ Release Clitoris, External Approach 0UQG0ZZ Repair Vagina, Open Approach 0UQJ0ZZ Repair Clitoris, Open Approach 0UQJXZZ Repair Clitoris, External Approach 0UTJ0ZZ Resection of Clitoris, Open Approach 0UTJXZZ Resection of Clitoris, External Approach 0UUG07Z Supplement Vagina with Autologous Tissue Substitute, Open Approach 0UUG0JZ Supplement Vagina with Synthetic Substitute, Open Approach 0UUG0KZ Supplement Vagina with Nonautologous Tissue Substitute, Open Approach 0UUG47Z Supplement Vagina with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 0UUG4JZ Supplement Vagina with Synthetic Substitute, Percutaneous Endoscopic Approach 0UUG4KZ Supplement Vagina with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 0UUG77Z Supplement Vagina with Autologous Tissue Substitute, Via Natural or Artificial Opening 0UUG7JZ Supplement Vagina with Synthetic Substitute, Via Natural or Artificial Opening 0UUG7KZ Supplement Vagina with Nonautologous Tissue Substitute, Via Natural or Artificial Opening 0UUG87Z Supplement Vagina with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic

32

0UUG8JZ Supplement Vagina with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic 0UUG8KZ Supplement Vagina with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic 0UUGX7Z Supplement Vagina with Autologous Tissue Substitute, External Approach 0UUGXJZ Supplement Vagina with Synthetic Substitute, External Approach 0UUGXKZ Supplement Vagina with Nonautologous Tissue Substitute, External Approach 0UUJ07Z Supplement Clitoris with Autologous Tissue Substitute, Open Approach 0UUJ0JZ Supplement Clitoris with Synthetic Substitute, Open Approach 0UUJ0KZ Supplement Clitoris with Nonautologous Tissue Substitute, Open Approach 0UUJX7Z Supplement Clitoris with Autologous Tissue Substitute, External Approach 0UUJXJZ Supplement Clitoris with Synthetic Substitute, External Approach 0UUJXKZ Supplement Clitoris with Nonautologous Tissue Substitute, External Approach 0VT90ZZ Resection of Right Testis, Open Approach 0VT94ZZ Resection of Right Testis, Percutaneous Endoscopic Approach 0VTB0ZZ Resection of Left Testis, Open Approach 0VTB4ZZ Resection of Left Testis, Percutaneous Endoscopic Approach 0VTC4ZZ Resection of Bilateral Testes, Percutaneous Endoscopic Approach 0VTS0ZZ Resection of Penis, Open Approach 0VTS4ZZ Resection of Penis, Percutaneous Endoscopic Approach 0VTSXZZ Resection of Penis, External Approach 0W4N071 Creation of Penis in Female Perineum with Autologous Tissue Substitute, Open Approach 0W4N0J1 Creation of Penis in Female Perineum with Synthetic Substitute, Open Approach 0W4N0K1 Creation of Penis in Female Perineum with Nonautologous Tissue Substitute, Open Approach

According to the policy statement above, the following CPT codes are considered investigational for the conditions listed for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT codes Code Description 15771 Liposuction/fat transfer to buttocks
15773 Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate 15774 Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure) 15839 Buccal fat pad removal
53899 Removal of urethral

Endnotes

1 Based on expert opinion