902 Form

Electrolysis for Gender Affirming Services (Transgender Services)
Prior Authorization Request Form #902

Medical Policy #189 Gender Affirming Services (Transgender Services)

CLINICAL DOCUMENTATION
▪ Clinical documentation that supports the medical necessity criteria for hair electrolysis for gender affirming surgery after scheduled bottom surgery or post surgery must be submitted.
▪ If the patient does not meet all the criteria listed below, please submit a letter of medical necessity with a request for Clinical Exception (Individual Consideration) explaining why an exception is justified.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the service request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources • Refer to our Authorization Manager page for tips, guides, and video demonstrations. Complete Prior Authorization Request Form for Electrolysis for Gender Affirming Services (902) using Authorization Manager.

For out of network providers: Requests should still be faxed to: BCBSMA Members: 888-282-0780

Medicare Advantage Members: 800-447-2994

Patient Information Patient Name:

Today’s Date: BCBSMA ID#:

Date of Treatment: Date of Birth:

Surgical Date:

Physician Information Facility Information MD/Servicing Provider Info:

Name:
Address:

Address: Phone #:

Phone #: Fax#:

Fax#: NPI#:

NPI # if applicable:

• 2 -

  Clinical Documentation – Please submit a Letter of Medical Necessity (LOMN) which includes the following: Diagnosis Procedure/CPT code Reason for continued service Site of service Name, address, credentials of servicing provider Area to be treated Initial service (12 sessions) Additional service beyond initial 12 (indicate how many session are expected) Description of what the skin graft will be used for

  Please verify the procedure being requested is the following:
  Electrolysis or laser hair removal performed by a licensed provider for the removal of hair on skin being used for genital gender affirmation surgery.
  

  *Bottom surgery consult note must be included.

  Physician’s signature: _

  The above requested information is required for the claim to process. Failure to submit this information in full may result in prior authorization denial or incomplete claims processing.