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Medical Coverage Policy: 0266
Medical Coverage Policy
Effective Date .................... 1/15/2024
Next Review Date .............. 1/15/2025
Coverage Policy Number ............. 0266
Gender Dysphoria Treatment
Table of Contents
Overview ............................................ 2
Coverage Policy .................................... 2
General Background ............................. 7
Medicare Coverage Determinations ....... 11
Coding Information ............................. 11
References ........................................ 17
Revision Details ................................. 19
Related Coverage Resources
Blepharoplasty, Reconstructive Eyelid Surgery,
and Brow Lift - (0045)
Breast Reconstruction Following Mastectomy or
Lumpectomy - (0178)
Dermabrasion and Chemical Peels - (0505)
Endometrial Ablation - (0013)
Histrelin Acetate Subcutaneous Implant -
(IP0133)
Infertility Injectables - (1012) (e.g., Lupron)
Infertility Services
Male Sexual Dysfunction Treatment:
Non-pharmacologic - (0403)
Oncology Medications - (1403) (e.g., Lupron,
Supprelin LA, Vantas, Zoladex)
Panniculectomy and Abdominoplasty - (0027)
Pharmacy Prior Authorization - (1407) (e.g.,
Lupron, Zoladex)
Preventive Care Services - (A004)
Breast Reduction - (0152)
Rhinoplasty, Vestibular Stenosis Repair and
Septoplasty - (0119)
Redundant Skin Surgery - (0470)
Speech Therapy - (0177)
Testosterone Therapy (Injectables and
Implantable Pellets) - (1503)
Triptorelin Pamoate - (IP0134) (Triptodor)
INSTRUCTIONS FOR USE
The following Coverage Policy applies to health benefit plans administered by Cigna Companies.
Certain Cigna Companies and/or lines of business only provide utilization review services to clients
and do not make coverage determinations. References to standard benefit plan language and
coverage determinations do not apply to those clients. Coverage Policies are intended to provide
guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please
note, the terms of a customer’s particular benefit plan document [Group Service Agreement,
Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan
document] may differ significantly from the standard benefit plans upon which these Coverage
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Policies are based. For example, a customer’s benefit plan document may contain a specific
exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s
benefit plan document always supersedes the information in the Coverage Policies. In the absence
of a controlling federal or state coverage mandate, benefits are ultimately determined by the
terms of the applicable benefit plan document. Coverage determinations in each specific instance
require consideration of 1) the terms of the applicable benefit plan document in effect on the date
of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including
Coverage Policies and; 4) the specific facts of the particular situation. Each coverage request
should be reviewed on its own merits. Medical directors are expected to exercise clinical judgment
where appropriate and have discretion in making individual coverage determinations. Where
coverage for care or services does not depend on specific circumstances, reimbursement will only
be provided if a requested service(s) is submitted in accordance with the relevant criteria outlined
in the applicable Coverage Policy, including covered diagnosis and/or procedure code(s).
Reimbursement is not allowed for services when billed for conditions or diagnoses that are not
covered under this Coverage Policy (see “Coding Information” below). When billing, providers
must use the most appropriate codes as of the effective date of the submission. Claims submitted
for services that are not accompanied by covered code(s) under the applicable Coverage Policy
will be denied as not covered. Coverage Policies relate exclusively to the administration of health
benefit plans. Coverage Policies are not recommendations for treatment and should never be used
as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support
medical necessity and other coverage determinations.
Overview
This Coverage Policy addresses treatment of gender dysphoria. Gender dysphoria is a condition
commonly described as a marked incongruence between one’s experienced/expressed gender and
primary and/or secondary sex characteristics; it has been described by the American Psychiatric
Association (2021) as “psychological distress that results from an incongruence between one’s sex
assigned at birth and one’s gender identity”.
The terms gender reassignment, gender confirming, and gender affirming are commonly used
interchangeably to describe the processes that an individual may undergo to transition to the
desired gender identity.
Coverage Policy
Coverage for treatment of gender dysphoria varies across plans. Coverage of drugs for
hormonal therapy, as well as whether the drug is covered as a medical or a pharmacy
benefit, varies across plans. Refer to the customer’s benefit plan document for coverage
details. In addition, coverage for treatment of gender dysphoria, including gender
reassignment surgery and related services may be governed by state and/or federal
mandates.
1
2
Some states require coverage of health services specific to treatment of gender
dysphoria which may be more or less restrictive than this coverage policy. Please access
applicable STATE SPECIFIC GUIDELINES prior to consideration of coverage for services
related to treatment of gender dysphoria.
1
New York regulated benefit plans do not include exclusions or plan language that limit coverage.
2
Washington State regulated benefit plans are subject to mandated coverage criteria.
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Unless otherwise specified in a benefit plan, the following conditions of coverage apply
for treatment of gender dysphoria and/or gender reassignment surgery and related
procedures, including all applicable benefit limitations, precertification, or other medical
necessity criteria.
Medically necessary treatment for an individual with gender dysphoria, including
nonbinary individuals diagnosed with gender dysphoria, may include ANY of the
following services:
• Behavioral health services, including but not limited to, counseling for gender dysphoria and
related psychiatric conditions (e.g., anxiety, depression).
• Hormonal therapy, including but not limited to androgens, anti-androgens, GnRH analogues*,
estrogens, and progestins (Prior authorization requirements may apply).
*Note: If use in adolescents, individual should have reached Tanner stage 2 of puberty
prior to receiving GnRH agonist therapy.
• Laboratory testing to monitor prescribed hormonal therapy.
• Age-related, gender-specific services, including but not limited to preventive health, as
appropriate to the individual’s biological anatomy (e.g., cancer screening [e.g., cervical,
breast, prostate], treatment of a prostate medical condition)
• Gender reassignment and related surgery (see below).
Gender Reassignment Surgery
Gender reassignment surgery, also known as gender affirmation surgery or gender
confirmation surgery, is considered medically necessary treatment of gender dysphoria
when the following criteria are met.
Notes:
• For New York regulated benefit plans (e.g., insured): case-by-case review by a
medical director for individuals under the age of 18 years of age will be given.
• California fully insured plans are not subject to utilization management for
gender dysphoria treatment, effective 10/25/2023.
• For reconstructive chest surgery ANY of the following criteria:
For initial mastectomy* for an individual ≥ age 17 years one letter of support from a
qualified mental health professional, who has evaluated the individual for gender dysphoria
and gives unequivocal support for the procedure being proposed.
For initial mastectomy* for an individual age 15 years to < age 17 years BOTH of the
following:
• Parental/guardian consent, when applicable
• Two separate letters of support, each from an independent mental health provider
experienced in adolescent mental health and the diagnosis and treatment of childhood
gender dysphoria. Each mental health evaluation must confirm a diagnosis of gender
dysphoria, confirm it is marked and sustained over time (e.g., two years), address any
mental health comorbidities, and document the individual’s emotional and cognitive
maturity necessary to provide informed consent.
Note: Initial mastectomy as part of gender reassignment surgery for an individual < than
age 15 years is considered not medically necessary.
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Breast augmentation for an individual age 18 years and older one letter of support from a
qualified mental health professional, who has evaluated the individual for gender dysphoria
and gives unequivocal support for the procedure being proposed.
*NOTE: The Women’s Health and Cancer Rights Act (WHCRA), 29 U.S. Code § 1185b requires
coverage of certain post-mastectomy services related to breast reconstruction and treatment of
physical complications from mastectomy including nipple-areola reconstruction.
• For hysterectomy, salpingo-oophorectomy, orchiectomy for an individual age 18
years or older:
recommendation for sex reassignment surgery (i.e., genital surgery) by a qualified
mental health professional who has evaluated the individual for gender dysphoria and
gives unequivocal clearance for the procedure being proposed.
• For reconstructive genital surgery for an individual age 18 years or older:
recommendation for sex reassignment surgery (i.e., genital surgery) by a qualified
mental health professional who has evaluated the individual for gender dysphoria and
gives unequivocal clearance for the procedure being proposed.
Table 1: Gender Reassignment Surgery: Covered Under Standard Benefit Plan Language
The procedures listed below are considered medically necessary under standard benefit
plan language when the above listed criteria for gender reassignment surgery have
been met, unless specifically excluded in the benefit plan language.
Procedure
CPT / HCPCS codes (This list may
not be all inclusive)
Intersex surgery, female to male (may involve staged
procedures to form a penis and scrotum using pedicle
flaps and free-skin graft, insertion of prostheses and
55980
57110
56625
58999
58999, 64856
used for phalloplasty, limited to eight 30-minute timed
17380
surgical correction of malfunctioning pump, cylinders,
54400, 54401, 54405, C1813, C2622
53410, 53430, 53450
58150, 58260, 58262, 58291, 58552,
58554, 58571, 58573, 58661
55175, 55180
54660
prosthesis testicular insertion
11970
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Procedure
CPT / HCPCS codes (This list may
not be all inclusive)
prosthesis, testicular prosthesis
11960, 11970, 11971, 54660
a genital reconstructive procedure
14041, 14301, 14302, 15100, 15101,
15738, 15757
19303
or post mastectomy reconstruction)
19350*
15200, 15201
19318
L8600, 17999
Intersex surgery, male to female (may involve staged
procedures to remove portions of male genitalia and
form female external genitals such as penectomy,
orchiectomy, vaginoplasty, clitoroplasty,
55970
15240, 15241, 57291, 57292, 57335
used to line the vaginal canal for vaginoplasty, limited
17380
54125
inversion)
56620, 56805
53430
56800
44145, 55899
54520, 54690
a genital reconstructive procedure
14301, 14302, 15750
with implants
15771-15772 (when specific to breast),
19325, 19340, 19342, C1789
15771, 15772
*Note: CPT 19318 (breast reduction) includes the work necessary to reposition and reshape the
nipple and areola. Therefore, CPT 19350 (nipple and areola reconstruction) is considered integral
to CPT 19318. Thus, these two codes cannot be billed together for “mastectomy” for the purpose
of gender reassignment. However, 19350 would be covered if requested along with 19303 as per
the federal mandate.
Table 2: Gender Reassignment Surgery: Other Procedures
Head and/or neck feminization/masculinization procedures listed below are considered
not medically necessary under standard benefit plan language. However, some benefit
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plans may expressly cover some or all of the procedures listed below for gender
dysphoria treatment.
In addition, please access applicable STATE SPECIFIC GUIDELINES prior to
consideration of coverage for services listed in Table 2 related to treatment of gender
dysphoria.
Head and/or Neck
Feminization/Masculinization
Procedures
CPT/HCPCS Code
Blepharoplasty
15820, 15821, 15822, 15823
Brow lift
67900
Cheek/malar implants
17999
Chin/nose implants, chin recontouring
21210, 21270, 30400, 30410, 30420, 30430
30435, 30450
Collagen injections, limited to facial
11950, 11951, 11952, 11954
Face lift
15824, 15825, 15826, 15828, 15829
Forehead reduction and contouring
21137, 21138, 21139, 21172, 21179, 21180
Facial bone reduction (osteoplasty)
21188, 21208, 21209
Jaw reduction, contouring, augmentation
21025, 21120, 21121, 21122, 21123, 21125,
21127, 21193
Laryngoplasty
31599
Lip lift and lip filling
40799
Rhinoplasty
21210, 21270, 30400, 30410, 30420, 30430,
30435, 30450
Skin resurfacing (e.g., dermabrasion,
chemical peels) limited to facial
15780, 15781, 15782, 15783, 15786, 15787,
15788, 15789, 15792, 15793
Thyroid reduction chondroplasty
31750
Neck tightening
15825
Electrolysis other than when performed pre-
vaginoplasty as outlined above (i.e., face,
neck) and limited to eight 30 minute timed
units per day
17380
Suction assisted lipoplasty, lipofilling, and/or
liposuction (i.e., head, neck)
15839, 15876
Voice therapy/voice lessons
92507
Voice modification surgery
31599, 31899
Table 3: Services Not Covered for Gender Reassignment
Not Covered Procedures CPT/HCPCS Code
Abdominoplasty
15847
Calf implants
17999
Hair transplantation
15775, 15776
Suction assisted lipoplasty, lipofilling, and/or
liposuction (i.e., body countouring of waist,
panniculectomy, thigh, leg, hip, buttock,
arm)
15830, 15832, 15833, 15834, 15835, 15836,
15837, 15838, 15877, 15878, 15879
Removal of redundant skin
15830, 15832, 15833, 15834, 15835, 15836
15837, 15838
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Not Covered Procedures CPT/HCPCS Code
Neck tightening, when not part of a covered
facial feminization procedure
15825
Lip enhancement, when not part of a
covered facial feminization procedure
40799
Buttock lift/gluteal augmentation
17999
Hair removal (e.g., electrolysis), other than
as noted above and/or greater than eight
30-minute timed units
17380
Laser hair removal, for any indication
17999
General Background
Gender dysphoria is described by the American Psychiatric Association (2021) as psychological
distress that results from an incongruence between one’s sex assigned at birth and one’s gender
identity. Gender identity refers to one’s psychological sense of their gender, whereas gender
expression refers to the outward manner in which one presents their gender. The causes of
gender dysphoria and the developmental factors associated with them are not well-understood.
Treatment of individuals with gender dysphoria varies, with some treatments involving a change in
gender expression or body modification.
Gender binary refers to two categories of gender: male and female. “Transgender” is a term that
describes an individual whose gender identity does not align with the gender assigned at birth but
may also refer to an individual whose sense of gender identity is binary and not traditionally
associated with that assigned at birth (APA, 2021). The term “transsexual” refers to an individual
whose gender identity is not congruent with their genetic and/or assigned sex and usually seeks
hormone replacement therapy (HRT) and possibly gender-affirmation surgery to feminize or
masculinize the body and who may live full-time in the crossgender role. Transsexualism is a form
of gender dysphoria. Other differential diagnoses include, but are not limited to, partial or
temporary disorders as seen in adolescent crisis, transvestitism, refusal to accept a homosexual
orientation, psychotic misjudgments of gender identity and severe personality disorders.
Individuals that are transsexual, transgender, or gender nonconforming (i.e., gender identity
differs from the cultural norm) may experience gender dysphoria. Cisgender refers to one whose
gender assigned at birth aligns with their gender identity (ACOG, 2021). Nonbinary is an umbrella
term that describes individuals who experience gender outside the gender binary of male or
female, these individuals may or may not consider themselves as transgender (WPATH 8, 2022).
Treatment of gender dysphoria is unique to each individual and may or may not involve body
modification. Some individuals require only psychotherapy, some require a change in gender
roles/expression, and others require hormone therapy and/or surgery to facilitate a gender
transition.
Health Equity: Healthcare inequities and poorer outcomes have been reported among
transgender individuals, and accessing healthcare can be challenging in many instances.
Furthermore, mental health and substance use disparities exist, as well as increased rates of HIV,
which have been reported in the medical literature among this population. The American College
of Obstetricians and Gynecologists (ACOG) reported in a Committee Opinion titled “Healthcare for
Transgender and Gender Diverse Individuals” (2021) that an estimated 150,000 youth (aged 13–
17 years) and 1.4 million adults (aged 18 years and older) living in the United States identify as
transgender. Similarly, in June 2022 the Williams Institute evaluated how many adults and youth
identify as transgender in the U.S. and reported that over 1.6 million adults (ages 18 and older)
and youth (ages 13 to 17) identify as transgender in the United States, or 0.6% of those ages 13
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and older (Herman, et. al., 2022). Furthermore, according to the Williams Institute (2022) an
analysis of data collected by the Centers for Disease Control and Prevention’s Behavioral Risk
Factor Surveillance System found differences between racial/ethnic groups are not statistically
significant, but their findings do reflect prior research with population-based samples that have
found that Latinx people, American Indian or Alaska Native, and biracial/multiracial groups appear
more likely than White people to identify as transgender. The authors note the estimates are
based on a modelling strategy and are comparable to weighted and unadjusted estimates, and
that the racial and ethnic distribution of adults and youth appear generally similar to the
racial/ethnic distribution of the U.S. population. However, youth and adults who identify as
transgender appear more likely to report being Latinx and less likely to report being White, as
compared the U.S. populations, consistent with prior research (Herman, et al., 2022).
Behavioral Health Services
Licensing requirements and scope of practice vary by state for healthcare professionals. The
recommended minimum credentials for a mental health professional to be qualified to evaluate or
treat adult individuals with gender dysphoria has been defined in the literature. There is some
consensus that in addition to general licensing requirements, a minimum of a Master’s or more
advanced degree from an accredited institution, an ability to recognize and diagnose coexisting
mental health concerns, and an ability to distinguish such conditions from gender dysphoria is
required.
Mental health professionals play a strong role in working with individuals with gender dysphoria as
they need to diagnose the gender disorder and any co-morbid psychiatric conditions accurately,
counsel the individual regarding treatment options, and provide psychotherapy (as needed) and
assess eligibility and readiness for hormone and surgical therapy. For children and adolescents,
the mental health professional should also be trained in child and adolescent developmental
psychopathology.
Once the individual is evaluated, the mental health professional provides documentation and
formal recommendations to medical and surgical specialists. Documentation for hormonal and/or
surgery should be comprehensive and include the extent to which eligibility criteria have been met
(i.e., confirmed gender dysphoria, capacity to make a fully informed decision, age ≥ 18 years or
age of majority, and other significant medical or behavioral health concerns are well-controlled),
in addition to the following:
• individual’s general identifying characteristics
• the initial and evolving gender, sexual and psychiatric diagnoses
• details regarding the type and duration of psychotherapy or evaluation the individual
received
• the mental health professional’s rationale for hormone therapy or surgery
• the degree to which the individual has followed recommended medical management and
likelihood of continued compliance
• whether or not the mental health professional is a part of a gender team
.
Psychiatric care may need to continue for several years after gender reassignment surgery, as
major psychological adjustments may continue to be necessary. Other providers of care may
include a family physician or internist, endocrinologist, urologist, plastic surgeon, general surgeon,
and gynecologist. The overall success of the surgery is highly dependent on psychological
adjustment and continued support.
After diagnosis, the therapeutic approach is individualized but generally includes three elements:
sex hormone therapy of the identified gender, real life experience in the desired role, and surgery
to change the genitalia and other sex characteristics.
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Hormonal Therapy
For both adults and adolescents, hormonal treatment for gender dysphoria must be administered
and monitored by a qualified healthcare practitioner as therapy requires ongoing medical
management, including physical examination and laboratory studies to manage dosage, side
effects, etc. Lifelong maintenance is usually required.
Adults: Prior to and following gender reassignment surgery, individuals may undergo hormone
replacement therapy. Biological males (i.e., assigned male at birth) are treated with estrogens and
anti-androgens to increase breast size, redistribute body fat, soften skin, decrease body hair, and
decrease testicular size and erections. Biological females (i.e., assigned female at birth) are
treated with androgens such as testosterone to deepen voice, increase muscle and bone mass,
decrease breast size, increase clitoris size, and increase facial and body hair. For some individuals
hormone replacement therapy (HRT) may be effective in reducing the adverse psychologic impact
of gender dysphoria. Hormone therapy is usually initiated upon referral from a qualified mental
health professional or a health professional competent in behavioral health and gender dysphoria
treatment specifically.
Adolescents: Adolescence is generally defined as the time between puberty and reaching the age
of majority (WPATH 8, 2022), an individual age 10 to 19 years (World Health Organization) or
until reaching age 21 years (American Academy of Pediatrics [AAP]). For some adolescents the
onset of puberty may worsen gender dysphoria. For these individuals puberty-suppressing
hormones (e.g., GnRH analogues) may be provided to individuals who have reached at least
Tanner stage 2 of sexual development (Hembree, et al., 2017; WPATH, 2022). Consistent with
adult hormone therapy, treatment of adolescents involves a multidisciplinary team, however when
treating an adolescent, a pediatric endocrinologist should be included as a part of the team. Pre-
pubertal hormone suppression differs from hormone therapy used in adults and may not be
without consequence; some pharmaceutical agents may cause negative physical side effects (e.g.,
height, bone growth).
Gender Reassignment Surgery
The term "gender reassignment surgery," also known as gender affirmation surgery, sexual
reassignment surgery, or gender confirming surgery may be part of a treatment plan for gender
dysphoria. The terms may be used to refer to either the reconstruction of male or female genitalia
specifically, or the reshaping by any surgical procedure of a male body into a body with female
appearance, or vice versa for an individual to function socially in the role to which they identify.
Such procedures that tend to display outward appearance generally include facial procedures,
chest reconstructive procedures as well as some genital reconstructive procedures (e.g.,
phalloplasty).
Performing gender reassignment surgery prior to age 18, or the legal age to give consent, is not
recommended by most professional societies (American College of Obstetricians and Gynecology
[ACOG], 2017; American Psychiatric Association (APA), 2012, Endocrine Society, 2017). Gender
reassignment surgery is intended to be a permanent change (non-reversible), establishing
congruency between an individual’s gender identity and physical appearance. Therefore, a careful
and accurate diagnosis is essential for treatment and can be made only as part of a long-term
diagnostic process involving a multidisciplinary specialty approach that includes an extensive case
history; gynecological, endocrine, and urological examination; and a clinical
psychiatric/psychological examination. Individuals who choose to undergo gender reassignment
surgery must be fully informed regarding treatment options with confirmation from the mental
health professional that the individual is considered a candidate for surgical treatment.
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At least six months of continuous hormone therapy is often prescribed prior to irreversible genital
surgery. Contraindications to hormonal therapy include but are not limited to hypercoagulability
conditions, known coronary artery disease, liver disease, and venous thromboembolism.
Other Associated Surgical Procedures
Services Otherwise Medically Necessary: Age-appropriate gender-specific services that would
otherwise be considered medically necessary remain medically necessary services for transgender
individuals, as appropriate to their biological anatomy. Examples include (but are not limited to):
• for female individuals transitioning to male (e.g., who have not undergone a mastectomy)
breast cancer screening
• for male individuals transitioning to female but who have retained the prostate gland,
cancer screening or treatment of a prostate condition.
Reversal of Gender Reassignment: Gender reassignment surgery is considered an irreversible
intervention. Although infrequent, surgery to reverse a partially or fully completed gender
reassignment (reversal of surgery to revise secondary sex characteristics), may be necessary
because of a complication (i.e., infection) or other medical condition necessitating surgical
intervention.
Masculinization/Feminization Procedures: Various other surgical procedures may be
performed as part of gender reassignment surgery, for example masculinization or feminization
procedures. When performed as part of gender reassignment surgery some procedures are
performed to assist with improving culturally appropriate male or female appearance
characteristics and may be considered not medically necessary. Please refer to the applicable
benefit plan document for terms, conditions, and limitations of coverage in addition to the
applicable Cigna Medical Coverage Policy for conditions of coverage.
Professional Society/Organization
American College of Obstetricians and Gynecologists (ACOG): ACOG published a Committee
Opinion in 2017 for the care of transgender adolescents. Within this document regarding surgical
management ACOG notes transgender male patients may undergo phalloplasty when one reaches
the age of majority, and a transgender female patient may undergo vaginoplasty when one
reaches the age of majority. In addition, the authors acknowledge the Endocrine Society
guidelines (Hembree, et al., 2009) which state that an individual is at least age 18 years for
genital reconstructive surgery (ACOG, 2017).
American Psychiatric Association (APA): In 2012 the APA published a task force report on
treatment of gender identity disorder. Within this document, regarding adolescents specifically,
the authors state the evidence is inadequate to develop a guideline regarding the timing of sex
reassignment surgery. However, the task force acknowledges the Endocrine Society guidelines
(Hembree, et al., 2009) and that given the irreversible nature of surgery, for adolescents most
clinicians advise waiting until the individual has attained the age of legal consent and a degree of
independence (APA, 2012).
WPATH Standards of Care: The World Professional Association for Transgender Health (WPATH)
promotes standards of health care for individuals through the articulation of “Standards of Care for
the Health of Transgender, and Gender Diverse People” (WPATH, 2022, Version 8). WPATH
standards of care are based on scientific evidence and expert consensus and are commonly
utilized as a clinical guide for individuals seeking treatment of gender disorders.
Endocrine Society: Updated guidelines by the Endocrine Society for endocrine treatment of
transsexual persons were published in 2017 (Hembree, et al., 2017). As part of this guideline, the
endocrine society recommends that transsexual persons consider genital sex reassignment
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surgery only after both the physician responsible for endocrine transition therapy and the mental
health professional find surgery advisable; that surgery be recommended only after completion of
at least one year of consistent and compliant hormone treatment; and that the physician
responsible for endocrine treatment medically clear the individual for sex reassignment surgery
and collaborate with the surgeon regarding hormone use during and after surgery.
Medicare Coverage Determinations
Contractor
Determination Name/Number
Revision Effective
Date
NCD
National
No determination found.
LCD
No determination found.
Note: Please review the current Medicare Policy for the most up-to-date information.
(NCD = National Coverage Determination; LCD = Local Coverage Determination)
Coding Information
Notes:
1. This list of codes may not be all-inclusive since the AMA and CMS code updates may occur
more frequently than policy updates.
2. Deleted codes and codes which are not effective at the time the service is rendered may
not be eligible for reimbursement.
Table 1: Gender Reassignment Surgery: Covered Under Standard Benefit Plan Language
Intersex Surgery: Female to Male
Considered Medically Necessary when criteria in the applicable policy statements listed
above are met:
CPT
®
*
Codes
Description
55980
Intersex surgery, female to male
11960
Insertion of tissue expander(s) for other than breast, including subsequent
expansion
11970
Replacement of tissue expander with permanent implant
11971
Removal of tissue expander without insertion of implant
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
14301
Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0
sq cm
14302
Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm,
or part thereof (List separately in addition to code for primary procedure)
15100
Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of
body area of infants and children (except 15050)
15101
Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each
additional 1% of body area of infants and children, or part thereof (List
separately in addition to code for primary procedure)
15200
Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm
or less
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CPT
®
*
Codes
Description
15201
Full thickness graft, free, including direct closure of donor site, trunk; each
additional 20 sq cm, or part thereof (List separately in addition to code for
primary procedure)
15738
Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
15757
Free skin flap with microvascular anastomosis
17380
†
Electrolysis epilation, each 30 minutes
17999
††
Unlisted procedure, skin, mucous membrane and subcutaneous tissue
19303
†††
Mastectomy, simple, complete
19318
†††
Breast reduction
19350
††††
Nipple/areola reconstruction
53410
Urethroplasty, 1-stage reconstruction of male anterior urethra
53430
Urethroplasty, reconstruction of female urethra
53450
Urethromeatoplasty, with mucosal advancement
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
54660
Insertion of testicular prosthesis (separate procedure)
55175
Scrotoplasty; simple
55180
Scrotoplasty; complicated
56625
Vulvectomy simple; complete
57110
Vaginectomy, complete removal of vaginal wall
58150
Total abdominal hysterectomy (corpus and cervix), with or without removal of
tube(s), with or without removal of ovary(s)
58260
Vaginal hysterectomy, for uterus 250 g or less
58262
Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or
ovary(s)
58291
Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s)
and/or ovary(s)
58552
Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with
removal of tube(s) and/or ovary(s)
58554
Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g;
with removal of tube(s) and/or ovary(s)
58571
Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with
removal of tube(s) and/or ovary(s)
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)
58999
†††††
Unlisted procedure, female genital system (nonobstetrical)
64856
Suture of major peripheral nerve, arm or leg, except sciatic; including
transposition
†
Note: Considered medically necessary when performed as electrolysis of donor site
tissue to be used for phalloplasty and limited to eight 30 minute timed units per day.
††
Note: Considered medically necessary when used to represent pectoral implants.
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Medical Coverage Policy: 0266
†††
Note: Considered medically necessary for an individual ≥ age 15 years when criteria
in the applicable policy statements above are met.
††††
Note: Considered medically necessary when performed as part of a mastectomy or
breast reconstruction procedure following a mastectomy. Considered integral and/or
not covered when performed with reduction mammoplasty.
†††††
Note: Considered medically necessary when used to report metoidioplasty with
phalloplasty.
Intersex Surgery: Male to Female
Considered Medically Necessary when criteria in the applicable policy statements listed
above are met:
CPT
®
*
Codes
Description
55970
Intersex surgery; male to female
14301
Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq
cm
14302
Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm,
or part thereof (List separately in addition to code for primary procedure)
15240
Full thickness graft, free, including direct closure of donor site, forehead, cheeks,
chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less
15241
Full thickness graft, free, including direct closure of donor site, forehead, cheeks,
chin, mouth, neck, axillae, genitalia, hands, and/or feet; each additional 20 sq cm,
or part thereof (List separately in addition to code for primary procedure)
15750
Flap; neurovascular pedicle
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)
17380
††
Electrolysis epilation, each 30 minutes
19325
Breast augmentation with implant
19340
Insertion of breast implant on same day of mastectomy (ie, immediate)
19342
Insertion or replacement of breast implant on separate day from mastectomy
44145
Colectomy, partial; with coloproctostomy (low pelvic anastomosis)
53430
Urethroplasty, reconstruction of female urethra
54125
Amputation of penis; complete
54520
Orchiectomy, simple (including subcapsular), with or without testicular prosthesis,
scrotal or inguinal approach
54690
Laparoscopy, surgical; orchiectomy
55899
†††
Unlisted procedure, male genital system
56620
Vulvectomy simple; partial
56800
Plastic repair of introitus
HCPCS
Codes
Description
C1813
Prosthesis, penile, inflatable
C2622
Prosthesis, penile, non-inflatable
L8600
Implantable breast prosthesis, silicone or equal
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Medical Coverage Policy: 0266
CPT
®
*
Codes
Description
56805
Clitoroplasty for intersex state
57291
Construction of artificial vagina; without graft
57292
Construction of artificial vagina; with graft
57335
Vaginoplasty for intersex state
†
Note: Considered medically necessary when used to report liposuction techniques
specific to breast augmentation.
††
Note: Considered medically necessary when performed as electrolysis of donor site
tissue to be used to line the vaginal canal for vaginoplasty and limited to eight 30 minute
timed units per day.
†††
Note: Considered medically necessary when used to report coloproctostomy.
ICD-10-CM
Diagnosis
Codes
Description
F64.0
Transsexualism
F64.1
Dual role transvestism
F64.2
Gender identity disorder of childhood
F64.8
Other gender identity disorders
F64.9
Gender identity disorder, unspecified
Z87.890
Personal history of sex reassignment
Table 2: Gender Reassignment Surgery: Other Procedures
Generally considered not medically necessary when performed as a component of
gender dysphoria treatment unless subject to a coverage mandate or specifically listed
as available in the applicable benefit plan document.
Note: For New York regulated benefit plans (e.g., insured): Subject to case by case
review by a medical director.
CPT
®
*
Codes
Description
11950
Subcutaneous injection of filling material (eg, collagen); 1 cc or less
11951
Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc
11952
Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc
11954
Subcutaneous injection of filling material (eg, collagen); over 10.0 cc
15780
Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general
keratosis)
15781
Dermabrasion; segmental, face
15782
Dermabrasion; regional, other than face
15783
Dermabrasion; superficial, any site (eg, tattoo removal)
15786
Abrasion; single lesion (eg, keratosis, scar)
HCPCS
Codes
Description
C1789
Prosthesis, breast (implantable)
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Medical Coverage Policy: 0266
CPT
®
*
Codes
Description
15787
Abrasion; each additional 4 lesions or less (List separately in addition to code for
primary procedure)
15788
Chemical peel, facial; epidermal
15789
Chemical peel, facial; dermal
15792
Chemical peel, nonfacial; epidermal
15793
Chemical peel, nonfacial; dermal
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
15829
Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap
15839
†
Excision, excessive skin and subcutaneous tissue (includes lipectomy); other
area
15876
Suction assisted lipectomy; head and neck
17380
††
Electrolysis epilation, each 30 minutes
17999
†††
Unlisted procedure, skin, mucous membrane and subcutaneous tissue
21025
Excision of bone (eg, for osteomyelitis or bone abscess); mandible
21120
Genioplasty; augmentation (autograft, allograft, prosthetic material)
21121
Genioplasty; sliding osteotomy, single piece
21122
Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or
bone wedge reversal for asymmetrical chin)
21123
Genioplasty; sliding, augmentation with interpositional bone grafts (includes
obtaining autografts)
21125
Augmentation, mandibular body or angle; prosthetic material
21127
Augmentation, mandibular body or angle; with bone graft, onlay or
interpositional (includes obtaining autograft)
21137
Reduction forehead; contouring only
21138
Reduction forehead; contouring and application of prosthetic material or bone
graft (includes obtaining autograft)
21139
Reduction forehead; contouring and setback of anterior frontal sinus wall
21172
Reconstruction superior-lateral orbital rim and lower forehead, advancement or
alteration, with or without grafts (includes obtaining autografts)
21179
Reconstruction, entire or majority of forehead and/or supraorbital rims; with
grafts (allograft or prosthetic material)
21180
Reconstruction, entire or majority of forehead and/or supraorbital rims; with
autograft (includes obtaining grafts)
21188
Reconstruction midface, osteotomies (other than LeFort type) and 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
21210
Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
21270
Malar augmentation, prosthetic material
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Medical Coverage Policy: 0266
CPT
®
*
Codes
Description
30400
Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
30410
Rhinoplasty, primary; complete, external parts including bony pyramid, lateral
and alar cartilages, and/or elevation of nasal tip
30420
Rhinoplasty, primary; including major septal repair
30430
Rhinoplasty, secondary; minor revision (small amount of nasal tip work)
30435
Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
30450
Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)
31599
††††
Unlisted procedure, larynx
31750
Tracheoplasty; cervical
31899
†††††
Unlisted procedure, trachea, bronchi
40799
††††††
Unlisted procedure, lips
67900
Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
92507
Treatment of speech, language, voice, communication, and/or auditory
processing disorder; individual
†
Note: Generally not medically necessary unless limited to face and neck, specified in
the applicable benefit plan document and limited to eight 30 minute timed units per day.
††
Note: Generally not medically necessary unless limited to face and neck, specified in
the applicable benefit plan document and limited to eight 30 minute timed units per day.
†††
Note: Generally not medically necessary when used to report cheek and malar
implants or fat transfers performed in conjunction with gender reassignment surgery,
unless specified in the applicable benefit plan document.
††††
Note: Generally not medically necessary when used to report laryngoplasty and/or
voice modification surgery performed in conjunction with gender reassignment surgery,
unless specified in the applicable benefit plan document.
†††††
Note: Generally not medically necessary when used to report voice modification
surgery performed in conjunction with gender reassignment surgery, unless specified in
the applicable benefit plan document.
††††††
Note: Generally not medically necessary when used to report lip
reduction/enhancement performed in conjunction with gender reassignment surgery,
unless specified in the applicable benefit plan document.
Table 3: Services Not Covered for Gender Reassignment
Considered Not Covered even if benefits are available for gender dysphoria treatment:
CPT
®
*
Codes
Description
15775
Punch graft for hair transplant; 1 to 15 punch grafts
15776
Punch graft for hair transplant; more than 15 punch grafts
15825
Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)
15830
Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen,
infraumbilical panniculectomy
15832
Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
Page 17 of 19
Medical Coverage Policy: 0266
†
Note: Not covered when used to report electrolysis epilation when not part of a
covered facial feminization or genital reconstructive procedure.
††
Note: Not covered when used to report buttock lift/gluteal augmentation or calf
implants or laser hair removal for any indication.
†††
Note: Not covered when used to report lip reduction/enhancement when not part of a
covered facial feminization procedure.
*Current Procedural Terminology (CPT
®
) ©2023 American Medical Association: Chicago,
IL.
References
1. American Academy of Pediatrics (AAP). Ensuring Comprehensive care and support for
transgender and gender diverse children and adolescents. Policy statement. Pediatrics.
Volume 142(4): October 2018.
2. American College of Obstetricians and Gynecologists (ACOG). Healthcare for Transgender
Individuals. Committee Opinion. Number 512, December 2011. Obstet Gynecol
2011:118:1454-8
3. American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice;
American College of Obstetricians and Gynecologists’ Committee on Health Care for
Underserved Women. Health Care for Transgender and Gender Diverse Individuals: ACOG
Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-e88.
4. American Psychiatric Association (APA). Report of the APA task force on treatment of
gender identity disorder. Am J Psychiatry 169:8, August 2012.
CPT
®
*
Codes
Description
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)
15877
Suction assisted lipectomy; trunk
15878
Suction assisted lipectomy; upper extremity
15879
Suction assisted lipectomy; lower extremity
17380
†
Electrolysis epilation, each 30 minutes
17999
††
Unlisted procedure, skin, mucous membrane and subcutaneous tissue
40799
†††
Unlisted procedure, lips
Page 18 of 19
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5. American Psychiatric Association (APA) Gender Dysphoria. © 2021. American Psychiatri
Association. Accessed January 20, 2022. Available at URL address: psychiatry.org
6. Centers for Medicare and Medicaid Services. Proposed Decision Memo for Gender Dysphoria
and Gender Reassignment Surgery (CAG-00446N). June 2016. Accessed February 10,
2022. Available at URL address: https://www.cms.gov/medicare-coverage-
database/details/nca-proposed-decision-memo.aspx?NCAId=282
7. Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender
and Gender Diverse People, Version 8. International Journal of Transgender Health 2022,
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8. Committee on Adolescent Health Care. Committee Opinion No. 685: Care for Transgender
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Technology Assessment. NZHTA Report February 2002, Volume 1, Number 1. Accessed
February 10, 2022. Available at URL address: http://nzhta.chmeds.ac.nz/index.htm#tech
10. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. Text Revision (DSM-IV
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2000.
11. Flores, A.R., Brown, T.N.T., Herman, J.L. (2016). Race and Ethnicity of Adults who Identify
as Transgender in the United States. Los Angeles, CA: The Williams Institute.
12. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer WJ 3
rd
,
Spack NP, Tangpricha V, Montori VM; Endocrine Society. Endocrine treatment of
transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol
Metab. 2009 Sep;94(9):3132-54.
13. Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal
SM, Safer JD, Tangpricha V, T'Sjoen GG. Endocrine Treatment of Gender-
Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.
Endocr Pract. 2017 Dec;23(12):1437.
14. Herman, J.L., Flores, A.R., Brown, T.N.T., Wilson, B.D.M., & Conron, K.J. (2017). Age of
Individuals who Identify as Transgender in the United States. Los Angeles, CA: The
Williams Institute.
15. Herman JL, Flores AR, O’Neill KK. How many adults and yout identify as transgender in the
United States? June 2022. UCLA School of Law. Williams Institute. Accesed August 26,
2022. Available at URL address: https://williamsinstitute.law.ucla.edu/publications/trans-
adults-united-states/
16. Landen M, Walinder J, Hambert G, Lundstrom B. Factors predictive of regret in sex
reassignment. Acta Psychiatr Scand. 1998 Apr;97(4):284-9.
17. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex
reassignment surgery. Arch Sex Behav. 2003 Aug;32(4):299-315.
Page 19 of 19
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18. Maharaj NR, Dhai A, Wiersma R, Moodley J. Intersex conditions in children and
adolescents: surgical, ethical, and legal considerations. J Pediatr Adolesc Gynecol. 2005
Dec;18(6):399-402.
19. Milrod C, Karasic DH. Age Is Just a Number: WPATH-Affiliated Surgeons' Experiences and
Attitudes Toward Vaginoplasty in Transgender Females Under 18 Years of Age in the United
States. J Sex Med. 2017 Apr;14(4):624-634.
20. Moore E, Wisniewski A, Dobs A. Endocrine treatment of transsexual people: a review of
treatment regimens, outcomes, and adverse effects. J Clin Endocrinol Metab. 2003
Aug;88(8):3467-73.
21. 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 Apr;40(4):472-81.
22. Sutcliffe PA, Dixon S, Akehurst RL, Wilkinson A, Shippam A, White S, Richards R, Caddy
CM. Evaluation of surgical procedures for sex reassignment: a systematic review. J Plast
Reconstr Aesthet Surg. 2009 Mar;62(3):294-306; discussion 306-8.
23. The Women’s Health and Cancer Rights Act of 1998 (WHCRA), 29 U.S. Code § 1185b -
Required coverage for reconstructive surgery following mastectomies.
24. World Professional Association for Transgender Health (WPATH). Position on rapid onset
gender dysphoria. 9/4/2018. Accessed February 10, 2022. Available at URL Address:
https://www.wpath.org/publications/soc
25. Zucker KJ. Intersexuality and gender identity disorder. J Pediatr Adolesc Gynecol. 2002
Feb;15(1):3-13.
Revision Details
Type of Revision
Summary of Changes
Date
Annual
No changes.
1/15/2024
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