Prior authorization request form Form

Effective Date

Last Reviewed

Original Document

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Definitions Gender dysphoria General descriptive term that refers to an individual’s discontent with the assigned gender. It is more specifically defined when used as a diagnosis. See APPENDIX to view complete DSM-5-TR Gender Dysphoria definition Transgender Refers to the broad spectrum of individuals who transiently or persistently identify with a gender different from their gender at birth. Transsexual Refers to an individual who seeks, or has undergone, a social transition from male to female or female to male. In many, but not all, cases this also involves a physical transition through cross-sex hormone treatment and genital surgery. Hormone therapy The administration of androgens to genotypic and phenotypic females and estrogen or progesterones to genotypic or phenotypic males for the purpose of effecting somatic changes to more closely approximate the physical appearance of the genotypically other sex.1
Hormones are also utilized for pubertal suppression. Gender affirming genital surgery
Genital surgery that alters the morphology to approximate the physical appearance of the genetically other sex. The surgical procedures in the table below (occurring in the

1 Hormonal gender reassignment does not refer to the administration of hormones for the purpose of medical care or research conducted for the treatment or study of non–gender-dysphoric medical conditions (i.e., aplastic anemia, impotence, cancer).

Page 2 of 13 absence of any diagnosable birth defect or other medically defined pathology [except gender dysphoria]) are included in this category. Gender non-conforming (TGNC-Transgender/ Gender Non-Conforming) Also referred to as non-binary. Gender nonconformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex.
Non-binary The individual’s identity does not exist as a dichotomy of male or female (binary) but rather identifies as belonging to neither male nor female genders and prefer pronouns such as they and them, and possibly label themselves as Gender Non-Conforming.

Common Medically Necessary Procedures

Breast augmentation* Breast reduction mammaplasty (trial of hormone therapy not pre-requisite) Clitoroplasty
Hysterectomy
Labioplasty
Mastectomy (trial of hormone therapy not pre-requisite) Metoidioplasty
Oophorectomy
Orchiectomy
Penectomy
Phalloplasty ±
Prostatectomy
Salpingectomy
Scrotoplasty
Testicular/penile prosthesis implantation
Urethroplasty
Vaginectomy Vaginoplasty ±
Vulvectomy
Vulvoplasty

Breast augmentation is considered medically necessary provided that the member has completed a minimum of 24 months of hormone therapy, during which time breast growth has been negligible; or hormone therapy is medically contraindicated; or the member is otherwise unable to take hormones ± Genital electrolysis is not considered a surgical procedure, but is performed in conjunction with genital surgery (i.e., when required for vaginoplasty or phalloplasty)

Page 3 of 13 Guideline A. Hormone therapy (whether or not in preparation for gender affirming surgery) will be covered as follows:

Treatment with gonadotropin-releasing hormone agents (pubertal suppressants) when based upon a determination by a qualified medical professional that the member is eligible and ready for such treatment, i.e., that the member: a. Meets gender dysphoria diagnostic criteria
b. Has experienced puberty to at least Tanner stage 2 with pubertal changes resulting in increased gender dysphoria c. Does not suffer from psychiatric comorbidity that interferes with diagnostic work-up or treatment d. Has adequate psychological and social support during treatment e. Demonstrates knowledge and understanding of expected treatment-outcomes associated with pubertal suppressants and cross-sex hormones, as well as the medical and social risks and benefits of sex reassignment
Treatment with cross-sex hormones, including testosterone, cypionate, conjugated estrogen, and estradiol, for members greater than or equal to 16 years of age, when based upon a determination of medical necessity made by a qualified medical professional. (Members less than 18 years of age must meet Criteria # 1) Note: Requests for coverage of cross-sex hormones for members less than 16 years of age will be reviewed on a case-by-case basis. B. Gender affirming surgery will be covered for members greater than or equal to 18 years of age. The request must be accompanied by letters from two qualified licensed health professionals (New York State [NYS] for NYS members or Connecticut State [CTS] for CTS members), acting within the scope of his/her practice, who have independently assessed the member and are referring the member for the surgery. (Note: Only one letter is required for breast surgery) One letter must be from a psychiatrist, psychologist, psychiatric nurse practitioner (NP) or licensed clinical social worker (CSW) with whom the member has an established and ongoing relationship.
The other letter may be from a psychiatrist, psychologist, physician, psychiatric NP or licensed CSW who has only an evaluative role with the member
Together, the letters must establish that the member:
Has a persistent and well-documented case of gender dysphoria
Has received hormone therapy (not prerequisite for mastectomy) appropriate to member’s gender goals for a minimum of 12 months prior to seeking genital surgery (unless medically contraindicated or the member is otherwise unable to take hormones)
Has lived 12 months in gender role congruent with member’s gender identity (inclusive of binary and Nonbinary Gender) and has received mental health counseling, as deemed medically necessary, during that time (Note: Not required for breast surgery)
Has no other significant medical or mental health conditions that would be a contraindication to gender affirming surgery, or if so, that those are reasonably well-controlled prior to the gender affirming surgery
Has the capacity to make fully informed decisions and consent to treatment

Page 4 of 13 Limitations and Exclusions
A. Requests for gender affirming surgery for members less than 18 years will be reviewed on a case-by-case basis. B. The following services and procedures are excluded from coverage:

Cryopreservation, storage, and thawing of reproductive tissue (including all related services and charges)
Reversal of genital and/or breast surgery
Reversal of surgery to revise secondary sex characteristics
Reversal of any procedure resulting in sterilization C. Coverage is not available for any surgeries, services or procedures that are purely cosmetic (i.e., when performed solely to enhance appearance, but not to medically treat the underlying gender dysphoria). The following surgery, services and procedures will be reviewed on a case-by-case basis (including surgical revisions). It is expected that the clinical rationale for each requested procedure is specifically documented in the letter of medical necessity from the treating physician:
Abdominoplasty, blepharoplasty, neck tightening or removal of redundant skin
Breast, brow, face, or forehead lifts
Calf, cheek, chin, nose, or pectoral implants
Collagen injections
Drugs to promote hair growth or loss
Gluteal augmentation
Electrolysis (unless required for vaginoplasty or phalloplasty)
Facial bone reconstruction, reduction, or sculpturing (including jaw shortening) and rhinoplasty
Hair transplantation
Lip reduction
Liposuction
Thyroid chondroplasty
Voice therapy, voice lessons or voice modification surgery Procedure Codes 11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less 11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm 11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure) 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

Page 5 of 13 15769 Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia) 15771 Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate 15772 Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure) 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) 15775 Punch graft for hair transplant; 1 to 15 punch grafts 15776 Punch graft for hair transplant; more than 15 punch grafts 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 15824 Rhytidectomy; forehead 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 15826 Rhytidectomy; glabellar frown lines 15828 Rhytidectomy; cheek, chin, and neck 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy 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 19303 Mastectomy, simple, complete 19316 Mastopexy 19318 Reduction mammaplasty

Page 6 of 13 19325 Breast augmentation with 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 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) 21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) 21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 Osteoplasty, facial bones; reduction 21270 Malar augmentation, prosthetic material 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 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) 30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies 30465 Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) 31599 Unlisted procedure, larynx 40500 Vermilionectomy (lip shave), with mucosal advancement 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 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 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 54522 Orchiectomy, partial

Page 7 of 13 54660 Insertion of testicular prosthesis (separate procedure) 54690 Laparoscopy, surgical; orchiectomy 55150 Resection of scrotum 55175 Scrotoplasty; simple 55180 Scrotoplasty; complicated 55801 Prostatectomy, perineal, subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy) 55810 Prostatectomy, perineal radical; 55812 Prostatectomy, perineal radical; with lymph node biopsy(s) (limited pelvic lymphadenectomy) 55815 Prostatectomy, perineal radical; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes 55821 Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); suprapubic, subtotal, 1 or 2 stages 55831 Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); retropubic, subtotal 55840 Prostatectomy, retropubic radical, with or without nerve sparing; 55842 Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy(s) (limited pelvic lymphadenectomy) 55845 Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes 55866 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed 55899 Unlisted procedure, male genital system
55970 Intersex surgery; male to female 55980 Intersex surgery; female to male 56620 Vulvectomy simple; partial 56625 Vulvectomy simple; complete 56800 Plastic repair of introitus 56805 Clitoroplasty for intersex state 57106 Vaginectomy, partial removal of vaginal wall 57107 Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue 57110 Vaginectomy, complete removal of vaginal wall 57111 Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) 57291 Construction of artificial vagina; without graft 57292 Construction of artificial vagina; with graft 57295 Revision (including removal) of prosthetic vaginal graft; vaginal approach 57296 Revision (including removal) of prosthetic vaginal graft; open abdominal approach 57335 Vaginoplasty for intersex state

Page 8 of 13 57426 Revision (including removal) of prosthetic vaginal graft, laparoscopic approach 57530 Trachelectomy (cervicectomy), amputation of cervix (separate procedure) 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) 58152 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch)
58180 Supracervical abdominal hysterectomy (subtotal hysterectomy), 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) 58263 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele
58267 Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control
58270 Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele 58275 Vaginal hysterectomy, with total or partial vaginectomy 58280 Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele 58285 Vaginal hysterectomy, radical (Schauta type operation) 58290 Vaginal hysterectomy, for uterus greater than 250 g; 58291 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) 58292 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele 58294 Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele 58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less 58542 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) 58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g 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 67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

Page 9 of 13 Diagnosis Codes F64.0 Transsexualism F64.1 Gender Dysphoria (ICD 10 Code Diagnosis: Dual-Role Transvestism) F64.8 Other gender identity disorders
F64.9 Gender identity disorder, unspecified
Z87.890 Personal history of sex reassignment References Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association.

American Psychiatric Association. What is Gender Dysphoria. August 2022. https://www.psychiatry.org/patients-families/gender- dysphoria/what-is-gender-dysphoria. Accessed July 17, 2024. Chen, D., Hidalgo, M.A., Leibowitz, S., Leininger, J., Simons, L., Finlayson, C. and Garofalo, R., 2016. Multidisciplinary Care for Gender-Diverse Youth: A Narrative Review and Unique Model of Gender-Affirming Care. Transgender Health, 1(1), pp.117-123. Wylie C. Hembree, Peggy Cohen-Kettenis, Henriette A. Delemarre-van de Waal, Louis J. Gooren, Walter J. Meyer, Norman P. Spack, Vin Tangpricha, Victor M. Montori; Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, Volume 94, Issue 9 1 September 2009, Pages 3132–3154, https://doi.org/10.1210/jc.2009-0345. Wylie C Hembree, Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema, Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer, Vin Tangpricha, Guy G T’Sjoen; Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 11, 1 November 2017, Pages 3869–3903, https://doi.org/10.1210/jc.2017-01658 New York State Department of Health. New York State Medicaid Update. Jaunary 2017. Volume 33, number 1. https://www.health.ny.gov/health_care/medicaid/program/update/2017/2017-01.htm#transgender. Accessed July 17, 2024. Monstrey S, Hoebeke P, Dhont M, et al. Surgical therapy in transsexual patients: a multi-disciplinary approach. Acta Chir Belg. 2001;101:200-209.
Schechter, L.S., 2016. Gender confirmation surgery: an update for the primary care provider. Transgender Health, 1(1), pp.32-40. Smith YL, Cohen L, Cohen-Kettenis PT.
Postoperative psychological functioning of adolescent transsexuals: a Rorschach study. Arch Sex Behav. 2002;31:255-261.
Smith YL, van Goozen SH, Cohen-Kettenis PT. Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study. J Am Acad Child Adolesc Psychiatry. 2001;40:472-481. Specialty-matched clinical peer review. World Professional Association for Transgender Health, Inc. Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons. Version 8. 2022. https://www.wpath.org/publications/soc. Accessed July 17, 2024. eMedNY. Provider Manual. New York State Medicaid Program Physician Procedure Codes. Section 5 Surgery.
https://www.emedny.org/ProviderManuals/Physician/PDFS/Physician%20Procedure%20Codes%20Sect5.pdf. Accessed July 17,
Yarbrough, E. Transgender Mental Health. 2018, American Psychiatric Association. Endocr Pract. 2022 Apr;28(4):420-424. doi: 10.1016/j.eprac.2022.02.007. Epub 2022 Feb 22. Gender-Affirming Surgery: Perioperative Medical Care Sangyoon Jason Shin 1 , Anish Kumar 1 , Joshua D Safer 2
Endocr Pract. 2022 Apr;28(4):420-424. doi: 10.1016/j.eprac.2022.02.007. Epub 2022 Feb 22. Gender-Affirming Surgery: Perioperative Medical Care Sangyoon Jason Shin 1 , Anish Kumar 1 , Joshua D Safer 2

Page 10 of 13 APPENDIX
DSM-5-TR Gender Dysphoria in Children 302.6 (F64.2) A marked incongruence between one’s experienced/expressed gender and assigned gender, or at least 6 months duration, as manifested by at least six of the following
one of which must be Criterion A1):

A strong desire to be the other gender or an insistence that one is the other gender) or some alternative gender different from one’s assigned gender).
In boys (assigned gender), a strong preference for crossing-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
A strong preference for cross-gender roles in make-believe play or fantasy play
A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
A strong preference for playmates of the other gender
In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough-and-tumble play: or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.
A strong dislike of one’s sexual anatomy.
A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender. A. The condition is associated with clinical significant distress or impairment in social, school, or other important areas of functioning. Specify if:
With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 255.2 (E25.) congenital adrenal hyperplasia or 259.50 (E34.50) androgen insensitivity syndrome). Gender Dysphoria in Adolescent and Adults 302.85 (F64.0) A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following:
A marked incongruence between one’ experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
A strong desire for the primary and/or secondary sex characteristics of the other gender.
A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).

Page 11 of 13

A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender). B. The condition is associated with clinically significant distress or impairment in social occupational, or other important areas of functioning.
Specify if:
With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 255.2 (E25.) congenital adrenal hyperplasia or 259.50 (E34.50) androgen insensitivity syndrome).
Specify if:
Posttransition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen-namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a ntal male; mastectomy or phalloplasty in a natal female).
```
 Specifiers
```
The posttranstion specifier may be used in the context of continuing treatment procedures that serve to support the new gender assignment.
Other Specified Gender Dysphoria 302.6 (F64.8) This category applies to presentations in which symptoms characteristic of gender dysphoria that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for gender dysphoria. The other specified gender dysphoria category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for gender dysphoria. This is done by recording “other specified gender dysphoria” followed by the specific reason (e.g., “brief gender dysphoria”).
An example of presentation that can be specified using the “other specified” designation is the following: The current disturbance meets symptom criteria for gender dysphoria, but the duration is less than 6 months.
Unspecified Gender Dysphoria 302.6 (F64.9) This category applies to presentations in which symptoms characteristic of gender dysphoria that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for gender dysphoria. The unspecified gender dysphoria category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for gender dysphoria, and includes presentations in which there is insufficient information to make a more specific diagnosis.

Page 12 of 13 Revision History Company(ies)

  DATE

REVISION EmblemHealth Jul. 28, 2025 Transferred policy content to individual company branded template EmblemHealth ConnectiCare May 17, 2024 Added case-by-case language for surgical revision requests EmblemHealth ConnectiCare Jul. 14, 2023 Changed title from Gender Affirming/Reassignment Surgery to Gender Affirming Surgery and replaced “reassignment” with “affirming” throughout the policy Updated Appendix from DSM-5 to DSM-5-TR
Updated coding commensurate with New York State Department of Health eMedNY Provider Manual EmblemHealth ConnectiCare Nov. 12, 2021 Added the following CPT codes as medically necessary services: 11920, 11921, 11922, and 19350 EmblemHealth ConnectiCare Nov. 3, 2020 Added gluteal augmentation to case-by-case review list EmblemHealth ConnectiCare May 8, 2020 Specific to breast surgery:  Eliminated two-letter prerequisite
 Eliminated prerequisite requiring members to live 12 months in the gender congruent with the member’s gender identity
ConnectiCare Dec. 1, 20219 ConnectiCare adopts the clinical criteria of its parent corporation EmblemHealth and retires its policy EmblemHealth

Dec. 14, 2018 Correction of clerical errors in Limitations/Exclusions Section C EmblemHealth

Aug. 17, 2018 Added New York to title Added complete DSM V gender dysphoria definition
EmblemHealth

Jun. 8, 20188 Changed title from Gender Reassignment Surgery to Gender Affirming/Reassignment Surgery
Added non-conforming non-binary and definitions
Added the term “affirming” to the Hormone and Surgical sections to denote inclusiveness EmblemHealth

Apr. 11, 2018 Moved augmentation mammoplasty from Limitations/Exclusions section (depicted as case-by- case when clinical criteria met) to covered procedures list (using same clinical criteria) Removed age prerequisite for pubertal suppressants EmblemHealth

Feb. 9, 2018 Added breast reduction mammaplasty coverage for Medicaid members Lowered hormone therapy age eligibility from 18 to 16 years of age for pubertal suppressants Clarified the roll of medical necessity review for procedures that may be regarded as cosmetic
EmblemHealth

Aug. 11, 2017 Added breast reduction mammaplasty to covered procedures list (Commercial and Medicare only) EmblemHealth

Feb. 20, 2017 Removed outdated/subjective terminology Removed prerequisite that identified specific medical or mental health conditions which must be absent; clarifying, that no other significant medical or mental conditions should be present if contraindicated to surgery [or if so, reasonably well-controlled prior to surgery]) Lowered eligibility for coverage of hormonal services from 18 to 16 years of age Removed psychotherapy time-frame prerequisites and simplified requirements

Page 13 of 13 Added to Limitations/Exclusions: Voice therapy, voice lessons and voice modification surgery EmblemHealth

Jan. 13, 2016 Removed mammaplasty as a medically necessary procedure for MtF gender reassignment EmblemHealth

Jun. 20, 2015 Clarified which surgical procedures are considered medically necessary and which are not Added that hormone therapy is not pre-requisite to mastectomy Added that cryopreservation, storage and thawing of reproductive tissue is not reimbursable

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