Oscar Sex Reassignment Surgery (Gender Affirmation Surgery) (CG017) Form
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Gender dysphoria is a mental health condition characterized by clinically significant distress when one’s
gender identity is contrary to the sex which was assigned at birth. The Plan follows guideline standards
laid out by the World Professional Association for Transgender Health (WPATH) to determine the
appropriate medical necessity criteria and support we can provide for our members. Therefore, the Plan
considers sex reassignment surgery (gender affirmation surgery) medically necessary for members with
documented gender dysphoria who meet the criteria laid out in this guideline. Please see your plan
benefit and pharmacy policies for hormone therapy.
If the member is requesting infertility services due to iatrogenic infertility as a result of gender affirmation
services, please refer to the Plan's Oscar Clinical Guidelines: Diagnosis and Treatment of Infertility
(CG016). Please check the member's benefit plan for eligibility for infertility services.
Definitions
“Augmentation Mammaplasty” or “Breast Augmentation” is a surgical procedure to enlarge one or both
breasts.
1
“Aesthetic Surgery” refers to surgery that is not performed for functional reasons but instead to modify
the appearance of an individual. In the context of gender dysphoria, the purpose is to better
approximate the desired gender identity. This is contrasted from cosmetic surgery, where the procedures
may overlap with those categorized as “aesthetic”, but the intent is not to treat gender dysphoria.
“Eunuch” individuals are those assigned male at birth (AMAB) and wish to eliminate masculine
physical features, masculine genitals, or genital functioning. They also include those whose testicles have
been surgically removed or rendered nonfunctional by chemical or physical means and who identify as a
eunuch.
“Gender Identity” is a person’s innate, deeply-felt sense of being a man, woman, or neither, which may
or may not correspond to the sex listed on person’s birth certificate. Despite this, “gender” is often
assigned synonymously with “sex” at birth. Furthermore, “gender” most often coincides with “identity”
but can be expressed differently through behaviors, clothing, hairstyles, etc. (e.g., someone can identify
as male but express their gender as female).
“Gender Identity Disorder” is better known as “Gender Dysphoria" (“transexualism” or
“transgenderism”), which typically refers to a difference between the gender identity and the assigned
sex. This diagnosis can also be used when a person has a strong and persistent cross-gender
identification (not concurrent with a physical intersex condition or simply a desire for any perceived
cultural advantages of the other sex), marked by persistent discomfort with one’s sex, or a sense of
inappropriateness in the gender role of that sex, and causing clinically significant distress or impairment
in social, occupational or other important areas of functioning. Gender Identity Disorder was a diagnostic
classification in DSM-4-TR, which has been replaced by Gender Dysphoria in DSM-5-TR.
“Gender Incongruence” is no longer seen as pathological or a mental disorder in the
world health community, while Gender Dysphoria is a mental health condition diagnosed by Diagnostic
and Statistical Manual of Mental Disorders (DSM-5-TR). Gender Incongruence is recognized as a
condition in the International Classification of Diseases and Related Health Problems, 11th Version of the
World Health Organization (ICD-11) (not yet adopted in the U.S.)
“Gender Nonconforming” describes people whose gender expression is neither masculine, nor
feminine, or is different from traditional or stereotypic expectations of how a man or a woman should
appear or behave.
“Hormone Therapy” is the administration of exogenous endocrine agents to induce feminizing or
masculinizing bodily changes, such that a person can more closely approximate the physical appearance
of the genotypically other sex.
“Non-Binary Gender” or “Genderqueer” describes people whose gender expression is neither
masculine, nor feminine, including people who identify with no gender or with more than one gender.
2
“Sex” is a term for a person’s biological and physical characteristics and is typically assigned at birth. It
differs from gender in that it is an outward, physical characteristic where gender is a psychological,
emotional, and social identity.
“Sexual Orientation” refers to a person’s preferences of attraction or lack thereof with others.
“Sex Reassignment Surgery” or “Gender Affirmation Surgery” refers to surgery that alters the
morphology to approximate the physical appearance of the genetically other sex (male-to-female, or
female-to-male).
“Transsexual” refers to individuals whose sex differs from the sex listed on his/her original birth
certificate and has had or wishes to have gender reassignment surgery (GRS), or who receives hormone
therapy but does not wish to have GRS (nonoperative transsexuals), and lives full-time in his/her new
gender role.
“Transgender and gender diverse (TGD)” - this is a broad term to include as many members of varied
communities around the world with gender identities or expressions that differ from the gender socially
attributed to the sex assigned to them at birth.
Male-to-Female Genital Reassignment Surgery include, but not limited to the following procedures:
● “Cliteroplasty” is the surgical creation or alteration of a clitoris
● “Electrolysis” for hair removal is a procedure to permanently remove hair on skin used with
gender affirmation procedures.
● “Orchiectomy” is the surgical removal of one or both testicles.
● “Penectomy” is the surgical removal of the penis.
● “Urethroplasty” is the surgical alteration and revision of the urethra.
● “Vaginoplasty” is the surgical procedure that results in the construction or reconstruction of the
vagina.
● “Vulvoplasty” is the surgical repair or remodeling of the vulva.
Female-to-Male Genital Reassignment Surgery includes the following procedures:
● “Bilateral Salpingo-oophorectomy” is the removal of both ovaries and fallopian tubes.
● “Electrolysis” for hair removal is a procedure to permanently remove hair on skin used with
gender affirmation procedures.
● “Hysterectomy” is the surgical removal of all or part of the uterus.
● “Mastectomy” is the surgical removal of the whole breast. There are several different techniques
with varying aesthetic outcomes. For example, “Subcutaneous mastectomy” is the removal of
the breast but leaving the nipple-areolar complex.
● “Metoidioplasty” is a female-to-male gender reassignment surgery where the clitoris is released
so that it stands in a more forward position, with or without urethral lengthening.
● “Oophorectomy” is the surgical removal of one or both ovaries.
● “Phalloplasty” is the construction or reconstruction of a penis.
3
● “Salpingectomy” is the surgical removal of one or both fallopian tubes.
● “Scrotoplasty” is the construction or reconstruction of a scrotum.
● “Vaginectomy” is a surgical procedure to remove all or part of the vagina.
● “Vulvectomy” is a procedure in which the vulva is partly or completely removed.
Clinical Indications
General Clinical Indications
(Pleasecheckthemember’splanbenefits)
Gender affirming services are considered medically necessary when ALL the following are met:
1. The member has capacity to grant fully informed consent for treatment and associated risks; and
2. The member has persistent, well-documented gender dysphoria per DSM-5-TR Criteria for
Gender Dysphoria in Adults and Adolescents, defined as meeting both of the following:
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:
i.
ii.
iii.
iv.
v.
vi.
A marked incongruence between one’s experienced/expressed gender and
primary and/or secondary sex characteristics (or, in young adolescents, the
anticipated secondary sex characteristics); or
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); or
A strong desire for the primary and/or secondary sex characteristics of the other
gender; or
A strong desire to be of the other gender (or some alternative gender different
from one’s assigned gender); or
A strong desire to be treated as the other gender (or some alternative gender
different from one’s assigned gender); or
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); and
b. The condition is associated with clinically significant distress or impairment in social,
occupational, or other important areas of functioning; and
3. The member has received mental health screening and assessment with documentation from a
qualified mental health professional as part of a multidisciplinary team for gender affirming
procedures, as defined by:
a. A Psychiatrist (MD or DO), Psychologist (PhD or Masters), or other practitioner (MD, DO,
PA, or NP) who is licensed by their statutory body and specialized in transgender
medicine; and
b. Proficiency in using the Diagnostic Statistical Manual of Mental Disorders (DSM-5); and
c. Experience with or specialized in diagnosing and treating gender dysphoria; and
4.
If significant medical or mental health concerns are present, they must be reasonably well
controlled or under treatment; and
4
5. For adolescents, the member must have additional assessments to meet criteria:
a. A comprehensive biopsychosocial assessment should be completed with mental and/or
medical professionals as part of a multidisciplinary team; and
b. The member has adequate home support and involvement of parent(s)/guardian(s) in
the assessment process, unless their involvement is determined to be harmful to the
adolescent or not feasible; and
c. The member has realistic expectations regarding the possibilities and limitations of
surgery and a full understanding of the long-term consequences of surgical procedures;
and
d. The member has been evaluated for safety and 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.
Gonadectomy and Hysterectomy
Adults
Gonadectomy (oophorectomy or orchiectomy), hysterectomy, salpingo-oophorectomy, for the treatment
of gender dysphoria are considered medically necessary when ALL of the following clinical criteria are
met:
1. General Clinical Indications for gender affirming services are met; and
2. Age of majority (18 years or older); and
3. 1 evaluation from a qualified health care professional, who has competencies in the assessment
of transgender and gender diverse people, and is part of the multidisciplinary team managing
the medical and mental health of the member; and
4. The member has tolerated at least 6 months of continuous hormone therapy, unless
contraindicated or inconsistent with the member’s goals of gender identity; and
5. Reproductive options or fertility preservation have been discussed prior to gonadectomy
(oophorectomy or orchiectomy), hysterectomy, salpingo-oophorectomy; and
6. The member will be managed by a multidisciplinary team, risks and benefits discussed prior to
surgery, and follow-up assessments post-surgery.
Adolescents (For California and New York State Lines of Business Only)
Genderaffirmingservicesforadolescentsmaybeeligibleandsubjecttoplanbenefits.Membersless
thantheageofmajoritywillbeconsideredonacase-by-casebasisformedicalnecessityfor
gonadectomy,hysterectomy,orsalpingo-oophorectomy.Thememberhastoleratedatleast12months
ofgender-affirminghormonetherapyorlonger,unlesscontraindicatedorinconsistentwiththemember’s
goalsofgenderidentity.Reproductiveoptionsorfertilitypreservationhavebeendiscussedpriorto
thesesurgeries.Themembermustalsomeetcriteria#5underGeneralClinicalIndications.
5
Genital Reconstruction
Adults
Genital reconstruction procedures (cliteroplasty, urethroplasty, vaginoplasty, vulvoplasty, labiaplasty,
phalloplasty with or without penile prosthesis, scrotoplasty with or without scrotal prosthesis, or
metoidioplasty) for the treatment of gender dysphoria are considered medically necessary when ALL of
the following clinical criteria are met:
1. General Clinical Indications for gender affirming services are met; and
2. Age of majority (18 years or older); and
3. 1 evaluation from a qualified health care professional, who has competencies in the assessment
of transgender and gender diverse people, and is part of the multidisciplinary team managing
the medical and mental health of the member; and
4. The member has tolerated at least 6 months of continuous hormone therapy, unless
contraindicated or inconsistent with the member’s goals of gender identity; and
5. Reproductive options or fertility preservation have been discussed prior to genital
reconstruction; and
6. 1 year of full-time, continuous living in a gender role that conforms to the member’s gender
identity; and
7. The member will be managed by a multidisciplinary team, risks and benefits discussed prior to
surgery, and follow-up assessments post-surgery.
Adolescents (For California and New York State Lines of Business Only)
Genderaffirmingservicesforadolescentsmaybeeligibleandsubjecttoplanbenefits.Membersless
thantheageofmajoritywillbeconsideredonacase-by-casebasisformedicalnecessityforgenital
reconstruction.Thememberhastoleratedatleast12monthsofgender-affirminghormonetherapyor
longer,unlesscontraindicatedorinconsistentwiththemember’sgoalsofgenderidentity.Reproductive
optionsorfertilitypreservationhavebeendiscussedpriortothesesurgeries.Themembermustalso
meetcriteria#5underGeneralClinicalIndications.
Breast Procedures
Adults
Breast procedures (female-to-male mastectomy or male-to-female breast augmentation) for the
treatment of gender dysphoria is considered medically necessary when ALL of the following clinical
criteria are met:
1. General Clinical Indications for gender affirming services are met; and
2. Age of majority (18 years or older); and
3. 1 evaluation from a qualified mental health professional, who has independently assessed the
individual, but is part of the multidisciplinary team managing the member; and
4. The risk factor for breast cancer is assessed prior to breast augmentation or mastectomy with the
anticipated amount of remaining breast tissue; and
6
5. The member will be managed by a multidisciplinary team, risks and benefits discussed prior to
surgery, and follow-up assessments post-surgery; and
6. Hormone therapy is recommended, but not required for adolescents and adults prior to breast
procedures. In order to achieve the desired surgical result, 1 year of continuous hormone
therapy is recommended, unless contraindicated or inconsistent with the member’s goals. For
the member who is planning mastectomy or breast augmentation mammoplasty/implants,
hormone therapy may help maximize results.
Adolescents
Genderaffirmingservicesforadolescentsmaybeeligibleandsubjecttoplanbenefits.Membersless
thantheageofmajoritywillbeconsideredonacase-by-casebasisformedicalnecessityforbreast
procedures.Thememberhastoleratedatleast12monthsofgender-affirminghormonetherapyor
longer,unlesscontraindicatedorinconsistentwiththemember’sgoalsofgenderidentity.Themember
mustalsomeetcriteria#5underGeneralClinicalIndications.
Revision Surgery
Adults
Requests for revision surgery must be submitted with medical records demonstrating objective
examination. Revision surgery may be considered medically necessary for ONE of the following:
1. To treat complications; or
2. To correct dysfunction; or
3.
If, after the initial surgery, the appearance of the transgender body part is still outside the
normal variation in appearance of the member’s gender identity.
Adolescents
Genderaffirmingservicesforadolescentsaresubjecttoplanbenefits.Memberslessthantheageof
majoritywillbeconsideredonacase-by-casebasisformedicalnecessityforrevisionsurgery.The
membermustalsomeetcriteria#5underGeneralClinicalIndications.
_____________________________________________________________________________________________
Applicable to New York State Lines of Business: For the following sections, see Appendix A:
● Aesthetic or other Non-chest/genital Surgery
● Non-Surgical Services
● Experimental or Investigational / Not Medically Necessary
● Applicable Billing Codes
Applicable to California State Lines of Business: For the following sections, see Appendix B:
● Aesthetic or other Non-chest/genital Surgery
● Non-Surgical Services
● Experimental or Investigational / Not Medically Necessary
● Applicable Billing Codes
_____________________________________________________________________________________________
7
Non-Surgical Services (For New York State Lines of Business: See Appendix A; For California State Lines
of Business: See Appendix B)
Non-surgical services are considered medically necessary when the above General Clinical Indications
criteria are met; services include:
1. Psychotherapy to support the member through his/her gender transition
2. Vocal training with a speech language pathologist
3. Laboratory testing to monitor the safety and effectiveness of continuous hormone replacement
therapy
4. Breast cancer screening for female to male trans-identified individuals who have not undergone
a mastectomy
5. Prostate cancer screening for male to female trans-identified individuals who have retained their
prostate
6. Hair removal or electrolysis for skin used for genital reconstruction as part of gender affirmation
surgery performed by a licensed and/or certified provider
Continuous Hormone Therapy
Pleaserefertoyourpharmacybenefitandpharmacyguidelinesforself-administeredhormonetherapy.
The Plan considers hormone therapy for gender dysphoria before and/or after gender affirmation
surgery to be medically necessary when the following criteria are met:
1. Hormone replacement therapy in adults (age of majority) who are transitioning for the member’s
gender congruence goals when all of the following criteria are met:
a. The requested medication has been prescribed by a qualified healthcare professional for
persistent, well-documented gender dysphoria; and
b. The member has capacity to grant fully informed consent for treatment and associated
risks; and
c.
If significant medical or mental health concerns are present, the member must be
receiving appropriate treatment and the condition must be reasonably well controlled;
and
d. Health care professionals must inform and counsel all individuals seeking
gender-affirming medical treatment about the options available for fertility preservation
prior to initiating puberty suppression and prior to treating with hormone therapy.
2. Puberty-suppressing hormone therapy in adolescents for the member’s gender congruence
goals or gender nonconformity when ALL of the following criteria are met:
a. The requested medication has been prescribed by a qualified healthcare professional for
a long-lasting and intense pattern of gender nonconformity or gender dysphoria
(whether suppressed or expressed); and
b. The adolescent’s gender dysphoria emerged or worsened with the onset of puberty; and
c. The adolescent has reached Tanner stage 2 of puberty for pubertal suppression to be
initiated; and
8
d.
If any significant medical, behavioral health, or social concerns are present that may
interfere with treatment or adherence, the member must be receiving appropriate
treatment and the condition must be reasonably well controlled to start hormone
therapy; and
e. The adolescent has given informed consent and, particularly when the adolescent has
not reached the age of medical consent, the parent(s)/guardian(s) have consented to the
treatment and are involved in supporting the adolescent throughout the treatment
process; and
f. Health care professionals must inform and counsel all individuals seeking
gender-affirming medical treatment about the options available for fertility preservation
prior to initiating puberty suppression and prior to treating with hormone therapy.
Experimental or Investigational / Not Medically Necessary (For New York State Lines of Business: See
Appendix A; For California State Lines of Business: See Appendix B)
Drugs or Services to Treat Sexual Dysfunction
Drugs or services to treat sexual dysfunction are not considered medically necessary to treat gender
dysphoria.
Elective Reversal of Gender Affirming Services/ Surgery
Gender affirming surgery requires a team of providers and specialists to work with a patient in order to
decide whether it is the most appropriate treatment approach and intervention. It requires specific
criteria be met, over a period of time to ensure the surgery will meet the specific needs of the patient
and have minimal medical and psychological risks. The results of sex reassignment surgery are difficult to
reverse, as some of the procedures are irreversible (Djordjevic, 2016). There has been limited research to
examine the variables that correlate with worsened biological, psychological, or social conditions
following transition and occurrence is rare (Hall et al., 2021; Littman, 2021).
Cosmetic Services
Certain services may be considered cosmetic for the treatment of gender dysphoria services, as the
service is intended to enhance features rather than to correct an anatomical deformity or variation that is
outside the spectrum of normal for the desired gender. Therefore, the following services are considered
not medically necessary, including but not limited to the following:
1. Abdominoplasty
2. Blepharoplasty
3. Body contouring, such as masculinization of the torso and pectoral implants, lipofilling,
liposuction.
4. Botulinum toxin injections
5. Brow or forehead lift
6. Calf implants
7. Cheek, chin or nose implants
8. Facial feminization, including face lifts, jaw and facial bone reduction, and neck tightening
9
9. Gluteal augmentation
10. Hair removal for any other location or indication outside of what is noted above in Non-Surgical
Services
11. Hair transplantation
12. Lip augmentation, enhancement or reduction
13. Liposuction (e.g., suction assisted lipectomy)
14. Mastopexy
15. Panniculectomy
16. Rhinoplasty
17. Revision or reconstruction surgery, if the request is primarily cosmetic nature, not satisfied with
the surgical result, to reverse natural signs of aging, and/or if the criteria above is not otherwise
met
18. Skin resurfacing or removal of redundant skin, except when a direct result of a medically
necessary surgery
19. Speech therapy not provided by a speech language pathologist, as it is considered experimental
or investigational
20. Speech therapy performed in a group setting, as it is considered experimental or investigational
21. Thyroid chondroplasty or cartilage reduction (commonly referred to as “trachea shave” of the
Adam’s apple)
22. Voice modification surgery (e.g., laryngoplasty)
Applicable Billing Codes (For New York State Lines of Business: See Appendix A; For California State
Lines of Business: See Appendix B)
GenderAffirmingSurgery
CPT/HCPCS Codes considered medically necessary if criteria are met:
Code
Description
11950 - 11954
Subcutaneous injection of filling material (e.g., collagen) [For breast augmentation]
11970
11971
11980
Replacement of tissue expander with permanent prosthesis
Removal of tissue expander(s) without insertion of prosthesis
Subcutaneous hormone pellet implantation (implantation of estradiol and/or
testosterone pellets beneath the skin)
11981
Insertion, drug-delivery implant (ie, bioresorbable, biodegradable,
11982
11983
non-biodegradable)
Removal, non-biodegradable drug delivery implant
Removal with reinsertion, non-biodegradable drug delivery implant
10
14000 - 14001
Adjacent tissue transfer or rearrangement, trunk [medically necessary when used
for chest reconstruction only]
14041
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck,
axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm [medically
necessary when used for genital reconstruction only]
14301 - 14302
Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq
cm [medically necessary when used for genital reconstruction only]
15200 - 15201
Full thickness graft, free, including direct closure of donor site, trunk [medically
necessary when used for chest reconstruction only]
15734
Muscle, myocutaneous, or fasciocutaneous flap; trunk [medically necessary when
used for genital reconstruction only]
15740
Flap; island pedicle requiring identification and dissection of an anatomically
named axial vessel [medically necessary when used for genital reconstruction only]
15750
Flap; neurovascular pedicle [medically necessary when used for genital
reconstruction only]
17380
Electrolysis epilation, each 30 minutes [medically necessary for skin used for
genital affirmation surgery]
19301
Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy,
19303
19318
19325
19340
19342
19350
19357
segmentectomy)
Mastectomy, simple, complete
Breast Reduction
Breast augmentation with implant [Not applicable for pectoral implants after
female to male transition]
Insertion of breast implant on same day of mastectomy (ie, immediate)
Insertion or replacement of breast implant on separate day from mastectomy [Not
applicable for pectoral implants after female to male transition]
Nipple/areola reconstruction
Tissue expander placement in breast reconstruction, including subsequent
expansion(s)
19370 - 19371
Capsulotomy, capsulectomy
19380
53410
Revision of reconstructed breast
Urethroplasty, 1-stage reconstruction of male anterior urethra
11
53415
Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of
prostatic or membranous 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
53430
54120
54125
urethra; second stage
Urethroplasty, reconstruction of female urethra
Amputation of penis; partial
Amputation of penis; complete
54400, 54401,
Penile prosthesis
54405, 54406,
54408, 54410,
54411, 54415,
54416, 54417
54520
Orchiectomy, simple (including subcapsular), with or without testicular prosthesis,
54530
54660
54690
55150
55175
55180
55899
55970
55980
56620
56625
56625
56800
56805
56810
scrotal or inguinal approach
Orchiectomy, radical, for tumor; inguinal approach
Insertion of testicular prosthesis (separate procedure)
Laparoscopy, surgical; orchiectomy
Resection of scrotum
Scrotoplasty; simple
Scrotoplasty; complicated
Unlisted procedure, male genital system [Phallic reconstruction/Phalloplasty]
Intersex surgery; male to female
Intersex surgery; female to male
Vulvectomy simple; partial
Vulvectomy simple; complete
Vulvectomy simple; complete
Plastic repair of introitus
Clitoroplasty for intersex state
Perineoplasty, repair of perineum, nonobstetrical (separate procedure)
12
57106
57107
57110
57111
57291
57292
57295
57296
57335
57425
57426
Vaginectomy, partial removal of vaginal wall
Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue
(radical vaginectomy)
Vaginectomy, complete removal of vaginal wall
Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue
(radical vaginectomy)
Construction of artificial vagina; without graft
Construction of artificial vagina; with graft
Revision (including removal) of prosthetic vaginal graft; vaginal approach
Revision (including removal) of prosthetic vaginal graft; open abdominal approach
Vaginoplasty for intersex state
Laparoscopy, surgical, colpopexy (suspension of vaginal apex)
Revision (including removal) of prosthetic vaginal graft, laparoscopic approach
58150, 58180,
Hysterectomy
58260, 58262,
58275, 58280,
58285, 58290,
58291, 58541,
58542, 58543,
58544, 58550,
58552, 58553,
58554
58570
58571
58572
58573
Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with
removal of tube(s) and/or ovary(s)
Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g
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
13
77067
Screening mammography, bilateral (2-view study of each breast), including
84153
90785
computer-aided detection (CAD) when performed
Prostate specific antigen (PSA); total
Interactive complexity (List separately in addition to the code for primary
procedure)
90832, 90833,
Psychotherapy
90834, 90836,
90837, 90838
92507
Treatment of speech, language, voice, communication, and/or auditory processing
disorder; individual
92522
Evaluation of speech sound production (eg, articulation, phonological process,
apraxia, dysarthria)
92523
Evaluation of speech sound production (eg, articulation, phonological process,
apraxia, dysarthria); with evaluation of language comprehension and expression
92524
96372
A4280
C1813
C2622
J1071
J1380
J1950
J3121
J3145
J3315
J3316
J9202
J9217
J9218
J9219
(eg, receptive and expressive language)
Behavioral and qualitative analysis of voice and resonance
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug);
subcutaneous or intramuscular
Adhesive skin support attachment for use with external breast prosthesis, each
Prosthesis, penile, inflatable
Prosthesis, penile, non-inflatable
Injection, testosterone cypionate, 1 mg
Estradiol Valerate 10mg IM
Injection, leuprolide acetate (for depot suspension), per 3.75 mg
Injection, testosterone enanthate, 1 mg
Injection, testosterone undecanoate, 1 mg
Injection, triptorelin pamoate, 3.75 mg
Injection, triptorelin, extended-release, 3.75 mg
Goserelin acetate implant, per 3.6 mg
Leuprolide acetate (for depot suspension), 7.5 mg
Leuprolide acetate, per 1 mg
Leuprolide acetate implant, 65 mg
14
J9225
J9226
Histrelin implant (Vantas), 50 mg
Histrelin implant (Supprelin LA), 50 mg
L8000 - L8032
Breast and nipple prostheses
L8039
Breast prosthesis, not otherwise specified [Not applicable for pectoral implants
after female to male transition]
L8039
Breast prosthesis, not otherwise specified [Not applicable for pectoral implants
after female to male transition]
L8600
Implantable breast prosthesis, silicone or equal [Not applicable for pectoral
implants after female to male transition]
S0189
Testosterone pellet
ICD-10 codes considered medically necessary if criteria are met:
Code
F64.0
F64.1
F64.8
F64.9
Description
Transexualism [Gender identity disorder in adolescence and adulthood, Gender
dysphoria in adolescents and adults]
Dual role transvestism
Other gender identity disorders
Gender identity disorder, unspecified
Z87.890
Personal history of sex reassignment
ICD-10 codes notconsidered medically necessary for gender affirming surgery:
F52.0 - F52.9
Sexual dysfunction not due to a substance or known physiological condition
F64.2
Gender identity disorder of childhood
Q56.0 - Q56.4
Indeterminate sex and pseudohermaphroditism
Q90.0 - Q99.9
Chromosomal anomalies, not elsewhere classified
R37
Sexual dysfunction, unspecified
Codes not considered medically necessary for indications listed in this Guideline:
CPT/HCPCS codes notconsidered medically necessary:
Code
Description
15
11920 - 11922
Tattooing, intradermal introduction of insoluble opaque pigments to correct color
defects of skin
11950 - 11954
Subcutaneous injection of filling material (e.g., collagen)
15775
15776
Punch graft for hair transplant; 1 to 15 punch grafts
Punch graft for hair transplant; more than 15 punch grafts
15780 - 15787
Dermabrasion
15788 - 15793
Chemical peel
15819
Cervicoplasty
15820-15823
Blepharoplasty
15824 - 15828
Rhytidectomy [face-lifting]
15829
Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap
15830 - 15839
Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen,
infraumbilical panniculectomy
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, 15877,
Suction-assisted lipectomy
15878, 15879
17380
Electrolysis epilation, each 30 minutes [not medically necessary for any indication
outside of genital reconstruction]
19316
21087
Mastopexy
Nasal prosthesis
21120 - 21123
Genioplasty
21125 - 21127
Augmentation, mandibular body or angle; prosthetic material or with bone graft,
onlay or interpositional (includes obtaining autograft)
21193
Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without
bone graft
21194
Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with
bone graft (includes obtaining graft)
21195
Reconstruction of mandibular rami and/or body, sagittal split; without internal
rigid fixation
21196
Reconstruction of mandibular rami and/or body, sagittal split with internal rigid
fixation
16
21208
Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic
implant)
21210
21270
27299
Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
Malar augmentation, prosthetic material
Unlisted procedure, pelvis or hip joint [gluteal augmentation]
30400 - 30420
Rhinoplasty; primary
30430 - 30450
Rhinoplasty; secondary
30999
31599
31750
40650
67900
92508
Unlisted procedure, nose
Unlisted procedure, larynx [this code may be used for trachea shave procedures
or voice modification surgery]
Tracheoplasty; cervical
Repair lip, full thickness; vermilion only
Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
Treatment of speech, language, voice, communication, and/or auditory
processing disorder; group, 2 or more individuals
J0585
Botulinum toxin injections
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44. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex
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51. Smith YL, van Goozen SH, Cohen-Kettenis PT. Adolescents with gender identity disorder who
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Clinical Guideline Revision / History Information
Original Date: 8/1/2017
Reviewed/Revised: 1/18/2018, 7/31/2018, 7/23/2019, 7/21/2020, 12/31/2020, 9/1/2021, 12/1/2021,
1/26/2022, 4/25/2022, 01/31/2023, 05/02/2023, 07/19/2023
21
Clinical Guideline
Appendix A - Applicable to New York State Lines of Business
Clinical Indications for the Eunuch Member
For the member who is a eunuch in the State of New York, who is assigned male at birth (AMAB) and
wish to eliminate masculine physical features, masculine genitals, or genital functioning, the following
criteria apply:
1. The clinical criteria starting from General Clinical Indications, Gonadectomy, Genital
Reconstruction, to Revision Surgery on pages 4-7 apply; and/or
2. Aesthetic or other Non-chest/genital Surgery below; and/or
3. Continuous Hormone Therapy criteria below.
Aesthetic or other Non-chest/genital Surgery & Non-Surgical Services
Aesthetic or other Non-chest/genital Surgery
The following procedures/surgeries for the treatment of gender dysphoria is/are considered medically
necessary when the procedure-specific clinical criteria are met (when applicable):
1. General Clinical Indications for gender affirming services are met; and
2. Age of majority (18 years or older) or adolescents; and
3. 1 evaluation from a qualified health care professional, who has competencies in the assessment
of transgender and gender diverse people, and is part of the multidisciplinary team managing
the medical and mental health of the member; and
4. 1 year of full-time, continuous living in a gender role that conforms to the member’s gender
identity; and
5. Medical records support that the the requested procedure is intended to treat the underlying
gender dysphoria by correcting a feature discongruent with the member’s gender identity; and
6. Medical records support that the request procedure is not purely cosmetic in nature (i.e., solely
to enhance appearance); and
7. For body contouring:
a. The existing body contour is such that it causes significant well-documented distress
directly related to the member’s gender dysphoria; or
b. The specific requested procedure is directly expected to improve this distress; and
c. The requested service is one of the below:
i.
Mastectomy and/or creation of a male chest (with or without body contouring)
for transmasculine or gender diverse members; or
ii.
Breast augmentation (with or without body contouring) for transfeminine
members; or
iii.
iv.
Lipofilling, liposuction for breast/chest; or
Gluteal or pectoral implants on a case-by-case basis; and
22
8. For facial feminization or facial masculinization:
a. The existing facial feature is such that it causes significant well-documented distress
directly related to the member’s gender dysphoria; and
b. The specific requested procedure is directly expected to improve this distress; and
c. The requested service is one of the below:
i.
ii.
iii.
iv.
v.
vi.
Blepharoplasty; or
Brow lift; or
Cheek augmentation; or
Forehead contouring; or
Scalp advancement (only as needed in conjunction with forehead contouring); or
Rhinoplasty; or
vii.
Face lift or liposuction (only as needed in conjunction with one of the above
procedures); or
viii.
Neck lift (only if the excess skin impairs the outcome of the covered facial
feminization or masculinization procedures); or
ix.
Mandible reconstruction; and
9. For thyroid chondroplasty or cartilage reduction (commonly referred to as “trachea shave” of the
Adam’s apple), the member is undergoing male-to-female transition.
10. For voice modification surgery (e.g., laryngoplasty):
a. The member has tried 1 year of vocal training with a speech language pathologist; and
b. ONE of the following:
i.
ii.
The member is undergoing male-to-female transition; or
The member is undergoing female-to-male transition and 2 years of consistent
hormone use has not adequately addressed the vocal quality or is otherwise
contraindicated.
Non-Surgical Services
Non-surgical services are considered medically necessary when General Clinical Indications are met,
services include:
1. Psychotherapy to support the member through his/her gender transition
2. Vocal training with a speech language pathologist
3. Hair reconstruction (i.e., hair transplantation, hair removal/electrolysis) by a licensed and/or
certified provider
4. Laboratory testing to monitor the safety and effectiveness of continuous hormone replacement
therapy
5. Breast cancer screening for female to male trans-identified individuals who have not undergone
a mastectomy
6. Prostate cancer screening for male to female trans-identified individuals who have retained their
prostate
23
Continuous Hormone Therapy
Pleaserefertoyourpharmacybenefitandpharmacyguidelinesforself-administeredhormonetherapy.
The Plan considers hormone therapy for gender dysphoria before and/or after gender affirmation
surgery to be medically necessary when the following criteria are met:
1. Hormone replacement therapy in adults (age of majority) who are transitioning for the member’s
gender congruence goals when all of the following criteria are met:
a. The requested medication has been prescribed by a qualified healthcare professional for
persistent, well-documented gender dysphoria; and
b. The member has capacity to grant fully informed consent for treatment and associated
risks; and
c.
If significant medical or mental health concerns are present, the member must be
receiving appropriate treatment and the condition must be reasonably well controlled;
and
d. Health care professionals must inform and counsel all individuals seeking
gender-affirming medical treatment about the options available for fertility preservation
prior to initiating puberty suppression and prior to treating with hormone therapy.
2. Puberty-suppressing hormone therapy in adolescents for the member’s gender congruence
goals or gender nonconformity when ALL of the following criteria are met:
a. The requested medication has been prescribed by a qualified healthcare professional for
a long-lasting and intense pattern of gender nonconformity or gender dysphoria
(whether suppressed or expressed); and
b. The adolescent’s gender dysphoria emerged or worsened with the onset of puberty; and
c. The adolescent has reached Tanner stage 2 of puberty for pubertal suppression to be
initiated; and
d.
If any significant medical, behavioral health, or social concerns are present that may
interfere with treatment or adherence, the member must be receiving appropriate
treatment and the condition must be reasonably well controlled to start hormone
therapy; and
e. The adolescent has given informed consent and, particularly when the adolescent has
not reached the age of medical consent, the parent(s)/guardian(s) have consented to the
treatment and are involved in supporting the adolescent throughout the treatment
process; and
f. Health care professionals must inform and counsel all individuals seeking
gender-affirming medical treatment about the options available for fertility preservation
prior to initiating puberty suppression and prior to treating with hormone therapy.
Experimental or Investigational / Not Medically Necessary
Drugs or Services to Treat Sexual Dysfunction
Drugs or services to treat sexual dysfunction are not considered medically necessary to treat gender
dysphoria by the Plan.
24
Elective Reversal of Gender Affirmation Surgery
Gender affirming surgery requires a team of providers and specialists to work with a patient in order to
decide whether it is the most appropriate treatment approach and intervention. It requires specific
criteria be met, over a period of time to ensure the surgery will meet the specific needs of the patient
and have minimal medical and psychological risks. The results of sex reassignment surgery are difficult to
reverse, as some of the procedures are irreversible (Djordjevic, 2016). There has been limited research to
examine the variables that correlate with worsened biological, psychological, or social conditions
following transition and occurrence is rare (Hall et al., 2021; Littman, 2021).
Cosmetic Services
Certain services may be considered cosmetic for the treatment of gender dysphoria services, as the
service is intended to enhance features rather than to correct an anatomical deformity or variation that is
outside the spectrum of normal for the desired gender. Therefore, the following services are considered
not medically necessary, and include but not limited to the following:
1. Abdominoplasty
2. Botulinum toxin injections
3. Calf implants
4. Mastopexy
5. Panniculectomy
6. Skin resurfacing or removal of redundant skin, except when a direct result of a medically
necessary surgery
7. Speech therapy not provided by a speech language pathologist, as it is considered experimental
or investigational
8. Speech therapy performed in a group setting, as it is considered experimental or investigational
9. Revision or reconstruction surgery, if the request is primarily cosmetic nature, not satisfied with
the surgical result, to reverse natural signs of aging, and/or if the criteria above is not otherwise
met
Applicable Billing Codes
GenderAffirmationServices
CPT/HCPCS Codes considered medically necessary if criteria are met:
Code
Description
11950 - 11954
Subcutaneous injection of filling material (e.g., collagen)
11970
11971
Replacement of tissue expander with permanent prosthesis
Removal of tissue expander(s) without insertion of prosthesis
25
11980
Subcutaneous hormone pellet implantation (implantation of estradiol and/or
testosterone pellets beneath the skin)
11981
Insertion, drug-delivery implant (ie, bioresorbable, biodegradable,
11982
11983
non-biodegradable)
Removal, non-biodegradable drug delivery implant
Removal with reinsertion, non-biodegradable drug delivery implant
14000 - 14001
Adjacent tissue transfer or rearrangement, trunk [medically necessary when used
for chest reconstruction only]
14041
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck,
axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm [medically
necessary when used for genital reconstruction only]
14301 - 14302
Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq
cm [medically necessary when used for genital reconstruction only]
15200 - 15201
Full thickness graft, free, including direct closure of donor site, trunk [medically
necessary when used for chest reconstruction only]
15734
Muscle, myocutaneous, or fasciocutaneous flap; trunk [medically necessary when
used for genital reconstruction only]
15740
Flap; island pedicle requiring identification and dissection of an anatomically
named axial vessel [medically necessary when used for genital reconstruction only]
15750
Flap; neurovascular pedicle [medically necessary when used for genital
reconstruction only]
15771
Grafting of autologous fat harvested by liposuction technique to trunk, breasts,
scalp, arms, and/or legs; 50 cc or less injectate [For breast/chest procedures]
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) [For breast/chest
procedures]
15775
15776
15819
Punch graft for hair transplant; 1 to 15 punch grafts
Punch graft for hair transplant; more than 15 punch grafts
Cervicoplasty
15820-15823
Blepharoplasty
15824 - 15828
Rhytidectomy [face-lifting]
15829
Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap
26
15876, 15877,
Suction-assisted lipectomy
15878, 15879
17380
19301
19303
19318
19325
19340
19342
19350
19357
Electrolysis epilation, each 30 minutes
Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy,
segmentectomy)
Mastectomy, simple, complete
Reduction mammaplasty
Breast augmentation with implant
Insertion of breast implant on same day of mastectomy (ie, immediate)
Insertion or replacement of breast implant on separate day from mastectomy
Nipple/areola reconstruction
Tissue expander placement in breast reconstruction, including subsequent
expansion(s)
19370-19371
Capsulotomy, capsulectomy
19380
21087
Revision of reconstructed breast
Nasal prosthesis
21120 - 21123
Genioplasty
21125 - 21127
Augmentation, mandibular body or angle; prosthetic material or with bone graft,
21137
21139
21193
onlay or interpositional (includes obtaining autograft)
Reduction forehead; contouring only
Reduction forehead; contouring and setback of anterior frontal sinus wall
Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without
bone graft
21194
Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with
bone graft (includes obtaining graft)
21195
Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid
fixation
21196
Reconstruction of mandibular rami and/or body, sagittal split with internal rigid
fixation
21208
Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic
implant)
21209
Osteoplasty, facial bones; reduction
27
21210
21270
27299
Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
Malar augmentation, prosthetic material
Unlisted procedure, pelvis or hip joint [gluteal augmentation]
30400 - 30420
Rhinoplasty; primary
30430 - 30450
Rhinoplasty; secondary
30999
31599
31750
40650
67900
53410
53415
Unlisted procedure, nose
Unlisted procedure, larynx [this code may be used for trachea shave procedures or
voice modification surgery]
Tracheoplasty; cervical
Repair lip, full thickness; vermilion only
Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
Urethroplasty, 1-stage reconstruction of male anterior urethra
Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of
prostatic or membranous 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;
53430
54120
54125
second stage
Urethroplasty, reconstruction of female urethra
Amputation of penis; partial
Amputation of penis; complete
54400, 54401,
Penile prosthesis
54405, 54406,
54408, 54410,
54411, 54415,
54416, 54417
54520
Orchiectomy, simple (including subcapsular), with or without testicular prosthesis,
54530
54660
54690
scrotal or inguinal approach
Orchiectomy, radical, for tumor; inguinal approach
Insertion of testicular prosthesis (separate procedure)
Laparoscopy, surgical; orchiectomy
28
55150
55175
55180
55899
55970
55980
56620
56625
56625
56800
56805
56810
57106
57107
57110
57111
57291
57292
57295
57296
57335
57425
57426
Resection of scrotum
Scrotoplasty; simple
Scrotoplasty; complicated
Unlisted procedure, male genital system [Phallic reconstruction/Phalloplasty]
Intersex surgery; male to female
Intersex surgery; female to male
Vulvectomy simple; partial
Vulvectomy simple; complete
Vulvectomy simple; complete
Plastic repair of introitus
Clitoroplasty for intersex state
Perineoplasty, repair of perineum, nonobstetrical (separate procedure)
Vaginectomy, partial removal of vaginal wall
Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue
(radical vaginectomy)
Vaginectomy, complete removal of vaginal wall
Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue
(radical vaginectomy)
Construction of artificial vagina; without graft
Construction of artificial vagina; with graft
Revision (including removal) of prosthetic vaginal graft; vaginal approach
Revision (including removal) of prosthetic vaginal graft; open abdominal approach
Vaginoplasty for intersex state
Laparoscopy, surgical, colpopexy (suspension of vaginal apex)
Revision (including removal) of prosthetic vaginal graft, laparoscopic approach
58150, 58180,
Hysterectomy
58260, 58262,
58275, 58280,
58285, 58290,
58291, 58541,
58542, 58543,
29
58544, 58550,
58552, 58553,
58554
58570
58571
58572
58573
Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with
removal of tube(s) and/or ovary(s)
Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g
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
58940
77067
84153
90785
procedure)
Oophorectomy, partial or total, unilateral or bilateral
Screening mammography, bilateral (2-view study of each breast), including
computer-aided detection (CAD) when performed
Prostate specific antigen (PSA); total
Interactive complexity (List separately in addition to the code for primary
procedure)
90832, 90833,
Psychotherapy
90834, 90836,
90837, 90838
92507
Treatment of speech, language, voice, communication, and/or auditory processing
disorder; individual
92522
Evaluation of speech sound production (eg, articulation, phonological process,
apraxia, dysarthria)
92523
Evaluation of speech sound production (eg, articulation, phonological process,
apraxia, dysarthria); with evaluation of language comprehension and expression
92524
96372
A4280
C1813
(eg, receptive and expressive language)
Behavioral and qualitative analysis of voice and resonance
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug);
subcutaneous or intramuscular
Adhesive skin support attachment for use with external breast prosthesis, each
Prosthesis, penile, inflatable
30
C2622
Prosthesis, penile, non-inflatable
J1071
J1380
J1950
J3121
J3145
J3315
J3316
J9202
J9217
J9218
J9219
J9225
J9226
Injection, testosterone cypionate, 1 mg
Estradiol Valerate 10mg IM
Injection, leuprolide acetate (for depot suspension), per 3.75 mg
Injection, testosterone enanthate, 1 mg
Injection, testosterone undecanoate, 1 mg
Injection, triptorelin pamoate, 3.75 mg
Injection, triptorelin, extended-release, 3.75 mg
Goserelin acetate implant, per 3.6 mg
Leuprolide acetate (for depot suspension), 7.5 mg
Leuprolide acetate, per 1 mg
Leuprolide acetate implant, 65 mg
Histrelin implant (Vantas), 50 mg
Histrelin implant (Supprelin LA), 50 mg
L8000 - L8032
Breast and nipple prostheses
L8039
L8039
L8600
S0189
Breast prosthesis, not otherwise specified
Breast prosthesis, not otherwise specified
Implantable breast prosthesis, silicone or equal
Testosterone pellet
ICD-10 codes considered medically necessary if criteria are met:
Code
F64.0
F64.1
F64.8
F64.9
Description
Transexualism
Dual role transvestism
Other gender identity disorders
Gender identity disorder, unspecified
Z87.890
Personal history of sex reassignment
ICD-10 codes notconsidered medically necessary for sex reassignment surgery:
F52.0 - F52.9
Sexual dysfunction not due to a substance or known physiological condition
31
F64.2
Gender identity disorder of childhood
Q56.0 - Q56.4
Indeterminate sex and pseudohermaphroditism
Q90.0 - Q99.9
Chromosomal anomalies, not elsewhere classified
R37
Sexual dysfunction, unspecified
Codes not considered medically necessary for indications listed in this Guideline:
CPT/HCPCS codes notconsidered medically necessary:
Code
Description
11920 -11922
Tattooing, intradermal introduction of insoluble opaque pigments to correct color
defects of skin
15780 - 15787
Dermabrasion
15788 - 15793
Chemical peel
15830 - 15839
Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen,
infraumbilical panniculectomy
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)
19316
92508
Mastopexy
Treatment of speech, language, voice, communication, and/or auditory processing
disorder; group, 2 or more individuals
J0585
Botulinum toxin injections
32
Appendix B - Applicable to California State Lines of Business
Clinical Indications for the Eunuch Member
For the member who is a eunuch in the State of California, who is assigned male at birth (AMAB) and
wish to eliminate masculine physical features, masculine genitals, or genital functioning, the following
criteria apply:
1. The clinical criteria starting from General Clinical Indications, Gonadectomy, Genital
Reconstruction, to Revision Surgery on pages 4-7 apply; and/or
2. Aesthetic or other Non-chest/genital Surgery below; and/or
3. Continuous Hormone Therapy criteria below.
Aesthetic or other Non-chest/genital Surgery & Non-Surgical Services
Aesthetic or other Non-chest/genital Surgery
The following procedures/surgeries for the treatment of gender dysphoria is/are considered medically
necessary when the procedure-specific clinical criteria are met (when applicable):
1. General Clinical Indications for gender-affirming services are met; and
2. Age of majority (18 years or older) or adolescents; and
3. 1 evaluation from a qualified health care professional, who has competencies in the assessment
of transgender and gender diverse people, and is part of the multidisciplinary team managing
the medical and mental health of the member; and
4. 1 year of full-time, continuous living in a gender role that conforms to the member’s gender
identity; and
5. Medical records support that the the requested procedure is intended to treat the underlying
gender dysphoria by correcting a feature discongruent with the member’s gender identity
6. Medical records support that the request procedure is not purely cosmetic in nature (i.e., solely
to enhance appearance); and
7. For body contouring:
a. The existing body contour is such that it causes significant well-documented distress
directly related to the member’s gender dysphoria; or
b. The specific requested procedure is directly expected to improve this distress; and
c. The requested service is one of the below:
i.
Mastectomy and/or creation of a male chest (with or without body contouring)
for transmasculine or gender diverse members; or
ii.
Breast augmentation (with or without body contouring) for transfeminine
members; or
iii.
iv.
Lipofilling, liposuction for breast/chest; or
Gluteal or pectoral implants on a case-by-case basis; and
8. For facial feminization or facial masculinization:
a. The existing facial feature is such that it causes significant well-documented distress
directly related to the member’s gender dysphoria; and
33
b. The specific requested procedure is directly expected to improve this distress; and
c. The requested service is one of the below:
i.
ii.
iii.
iv.
v.
vi.
Blepharoplasty; or
Brow lift; or
Cheek augmentation; or
Forehead contouring; or
Scalp advancement (only as needed in conjunction with forehead contouring); or
Rhinoplasty; or
vii.
Face lift or liposuction (only as needed in conjunction with one of the above
procedures); or
viii.
Neck lift (only if the excess skin impairs the outcome of the covered facial
feminization or masculinization procedures); or
ix.
Mandible reconstruction; and
9. For thyroid chondroplasty or cartilage reduction (commonly referred to as “trachea shave” of the
Adam’s apple), the member is undergoing male-to-female transition.
10. For voice modification surgery (e.g., laryngoplasty):
a. The member has tried 1 year of vocal training with a speech language pathologist; and
b. ONE of the following:
i.
ii.
The member is undergoing male-to-female transition; or
The member is undergoing female-to-male transition and 2 years of consistent
hormone use has not adequately addressed the vocal quality or is otherwise
contraindicated.
Non-Surgical Services
Non-surgical services are considered medically necessary when the General Clinical Indications criteria
are met; services include:
1. Psychotherapy to support the member through his/her gender transition
2. Vocal training with a speech language pathologist
3. Hair reconstruction (i.e., hair transplantation, hair removal/electrolysis) performed by a licensed
and/or certified provider
4. Laboratory testing to monitor the safety and effectiveness of continuous hormone replacement
therapy
5. Breast cancer screening for female to male trans-identified individuals who have not undergone
a mastectomy
6. Prostate cancer screening for male to female trans-identified individuals who have retained their
prostate
Continuous Hormone Therapy
Pleaserefertoyourpharmacybenefitandpharmacyguidelinesforself-administeredhormonetherapy.
The Plan considers hormone therapy for gender dysphoria before and/or after gender affirmation
surgery to be medically necessary when the following criteria are met:
34
1. Hormone replacement therapy in adults (age of majority) who are transitioning for the member’s
gender congruence goals when all of the following criteria are met:
a. The requested medication has been prescribed by a qualified healthcare professional for
persistent, well-documented gender dysphoria; and
b. The member has capacity to grant fully informed consent for treatment and associated
risks; and
c.
If significant medical or mental health concerns are present, the member must be
receiving appropriate treatment and the condition must be reasonably well controlled;
and
d. Health care professionals must inform and counsel all individuals seeking
gender-affirming medical treatment about the options available for fertility preservation
prior to initiating puberty suppression and prior to treating with hormone therapy.
2. Puberty-suppressing hormone therapy in adolescents for the member’s gender congruence
goals or gender nonconformity when ALL of the following criteria are met:
a. The requested medication has been prescribed by a qualified healthcare professional for
a long-lasting and intense pattern of gender nonconformity or gender dysphoria
(whether suppressed or expressed); and
b. The adolescent’s gender dysphoria emerged or worsened with the onset of puberty; and
c. The adolescent has reached Tanner stage 2 of puberty for pubertal suppression to be
initiated; and
d.
If any significant medical, behavioral health, or social concerns are present that may
interfere with treatment or adherence, the member must be receiving appropriate
treatment and the condition must be reasonably well controlled to start hormone
therapy; and
e. The adolescent has given informed consent and, particularly when the adolescent has
not reached the age of medical consent, the parent(s)/guardian(s) have consented to the
treatment and are involved in supporting the adolescent throughout the treatment
process; and
f. Health care professionals must inform and counsel all individuals seeking
gender-affirming medical treatment about the options available for fertility preservation
prior to initiating puberty suppression and prior to treating with hormone therapy.
Experimental or Investigational / Not Medically Necessary
Drugs or Services to Treat Sexual Dysfunction
Drugs or services to treat sexual dysfunction are not considered medically necessary to treat gender
dysphoria by the Plan.
Elective Reversal of Sex Reassignment Surgery
Sex reassignment surgery requires a team of providers and specialists to work with a patient in order to
decide whether it is the most appropriate treatment approach and intervention. It requires specific
criteria be met, over a period of time to ensure the surgery will meet the specific needs of the patient
35
and have minimal medical and psychological risks. The results of sex reassignment surgery are difficult to
reverse, as some of the procedures are irreversible (Djordjevic, 2016). There has been limited research to
examine the variables that correlate with worsened biological, psychological, or social conditions
following transition and occurrence is rare (Hall et al., 2021; Littman, 2021).
Cosmetic Services
Certain services may be considered cosmetic for the treatment of gender dysphoria services, as the
service is intended to enhance features rather than to correct an anatomical deformity or variation that is
outside the spectrum of normal for the desired gender. Therefore, the following services are considered
not medically necessary and include, but not limited to the following:
1. Abdominoplasty
2. Botulinum toxin injections
3. Calf implants
4. Mastopexy
5. Panniculectomy
6. Skin resurfacing or removal of redundant skin, except when a direct result of a covered surgery
7. Speech therapy not provided by a speech language pathologist, as it is considered experimental
or investigational
8. Speech therapy performed in a group setting, as it is considered experimental or investigational
9. Revision or reconstruction surgery, if the request is primarily cosmetic nature, not satisfied with
the surgical result, to reverse natural signs of aging, and/or if the criteria above is not otherwise
met