Policy title: Gender Affirming Surgery

Policy number: MA 1.144

Fecha de entrada en vigor: 4/1/2026

Política

Gender affirming surgery may be considered medically necessary when all of the following pre-procedure criteria are met:

• Recommendation for surgical intervention by one qualified health care professional.
• A qualified health care professional, for purposes of this policy, is usually a licensed behavioral health care professional who holds a postgraduate degree. Other health care professionals who can document achievement of WPATH competencies can be considered; and
• The recommendation letter should include a comprehensive evaluation/report (comprehensive biopsychosocial assessment for adolescents) that documents all of the following:
• Marked and sustained gender incongruence or gender dysphoria. (see Appendix); and
• The individual has the capacity to make a fully informed decision and to consent for treatment; and
• Other possible causes of apparent gender incongruence have been identified and excluded; and
• Mental and physical health conditions that could negatively impact the outcome of gender affirming medical treatments are assessed, with risks and benefits discussed.
• Documentation of at least 6 months of continuous hormonal therapy as appropriate to the individual’s gender goals, (unless medically contraindicated or hormone therapy is not desired).
• Adolescents must have documentation of 12 months of continuous hormonal therapy as appropriate to the individual’s gender goals (unless medically contraindicated or hormone therapy is not desired).

Female to Male or Gender Diverse Transition:

When all of the pre-procedure criteria are met, the following breast and genital surgeries may be considered medically necessary for transmen or those that are gender diverse:

• Breast reconstruction (e.g., reduction mammaplasty)
• Hysterectomy
• Metoidioplasty
• Penile prosthesis insertion
• Phalloplasty
• Salpingo-oopherectomy
• Scrotoplasty
• Testicular prosthesis implantation
• Urethroplasty
• Vaginectomy
• Vulvectomy, simple, complete

Male to Female or Gender Diverse Transition:

When all of the pre-procedure criteria are met, the following breast and genital surgeries may be considered medically necessary for transwomen or those that are gender diverse:

• Breast augmentation
• Colovaginoplasty
• Clitoroplasty
• Labiaplasty
• Orchiectomy
• Penectomy
• Vulvoplasty
• Vaginoplasty

Other Gender Affirming Interventions:

When all of the pre-procedure criteria are met, the following procedures may be considered medically necessary when the intervention is expected to effectively treat the individual’s gender incongruence and/or dysphoria (this list may not be all-inclusive):

• Abdominoplasty
• Blepharoplasty
• Blepharoptosis
• Brow lift
• Calf augmentation/implants
• Cheek/malar implants
• Chin augmentation
• Collagen injections
• Cricothyroid approximation
• Dermabrasion/Skin resurfacing
• Facial feminizing/sculpturing (e.g., jaw shortening, forehead reduction)
• Forehead lift
• Hair removal – Electrolysis or laser hair removal
• Hair transplantation
• Laryngoplasty
• Lip reduction/enhancement
• Liposuction
• Mastopexy
• Nose implants
• Removal of redundant skin
• Rhinoplasty
• Rhytidectomy
• Scrotoplasty
• Trachea shave/reduction thyroid chondroplasty
• Voice modification surgery
• Voice therapy/voice lessons

Note: Additional procedures may be available based on an individual’s benefit.

Detransition, to include surgical intervention, may be considered medically necessary when all of the following criteria have been met:

• The individual is being cared for by a comprehensive multidisciplinary assessment team; and
• Social transition has been discussed and considered; and
• The individual has lived in the social role for a prolonged period of time (if recommended by the multidisciplinary team); and
• The assessing health care professional, who is a member of the comprehensive multidisciplinary assessment team, documents how detransition is in the best interest of the individual.

Esta política médica se aplica a los planes Medicare Advantage ofrecidos por Capital Blue Cross y sus subsidiarias.

Referencias cruzadas:

• MP 1.004 Cosmetic and Reconstructive Surgery
• MP 2.345 Subcutaneous Hormone Pellet Implants

Descripción/Antecedentes

Gender incongruence is defined as a condition in which the gender identity of a person does not align with the gender assigned at birth. Gender dysphoria refers to the psychological distress that results from an incongruence between one's sex assigned at birth and one's gender identity. Though gender dysphoria often begins in childhood, some people may not experience it until after puberty or much later.

Transgender and gender diverse (TGD) is a broad and comprehensive term that describes members of the many varied communities that exist globally of people with gender identities or expressions that differ from the gender socially attributed to the sex assigned to them at birth.

The goal of gender-affirming care is to partner with TGD people to holistically address their social, mental, and medical health needs and well-being while respectfully affirming their gender identity. Gender-affirming interventions include puberty suppression, hormone therapy, and gender-affirming surgeries among others. It should be emphasized there is no 'one-size-fits-all' approach and TGD people may need to undergo all, some, or none of these interventions to support their gender affirmation.

Gender affirming surgery is intended to be a permanent change, establishing congruency between an individual's gender identity and physical appearance and is not easily reversible. The choice to detransition is proportionally rare.

The American Medical Association (AMA) and the American Academy of Professional Coders (AAPC) gives guidance on coding reduction mammaplasty for gender affirmation. Per AMA, CPT code 19303 (mastectomy) is to be used for the treatment or prevention of breast cancer. AMA Section Guidelines state "when breast tissue is removed for breast-size reduction and not for treatment or prevention of breast cancer, report 19318 (reduction mammaplasty)".

Fundamento

Resumen de la evidencia

World Professional Association for Transgender Health (WPATH) Guidelines: “There is strong evidence demonstrating the benefits in quality of life and well-being of gender-affirming treatments, including endocrine and surgical procedures, properly indicated and performed as outlined by the Standards of Care (Version 8), in TGD people in need of these treatments. Gender-affirming interventions may also include hair removal/transplant procedures, voice therapy/surgery, counseling, and other medical procedures required to effectively affirm an individual’s gender identity and reduce gender incongruence and dysphoria. Gender-affirming interventions are based on decades of clinical experience and research; therefore, they are not considered experimental, cosmetic, or for the mere convenience of a patient. They are safe and effective at reducing gender incongruence and gender dysphoria.”

Definiciones

• Adolescent refers to the start of puberty until the legal age of majority.
• Gender diverse, per WPATH, gender diverse individuals have often been neglected and/or marginalized and include nonbinary, eunuch, and intersex individuals.

Exención de responsabilidad

Las políticas médicas de Capital Blue Cross se utilizan para determinar la cobertura de tecnologías, procedimientos, equipos y servicios médicos específicos. Estas políticas médicas no constituyen un consejo médico y están sujetas a cambios según lo permita la ley o la evidencia clínica aplicable de las pautas de tratamiento independientes. Los proveedores que brindan tratamiento son individualmente responsables de los consejos médicos y el tratamiento de los miembros. Estas políticas no son una garantía de cobertura o pago. El pago de las reclamaciones está sujeto a la determinación del programa de beneficios del miembro y la elegibilidad en la fecha del servicio, y a la determinación de que los servicios son médicamente necesarios y apropiados. El procesamiento final de una reclamación se basa en los términos del contrato que se aplican al programa de beneficios de los miembros, incluidas las limitaciones y exclusiones de beneficios. Si un proveedor o miembro tiene alguna pregunta sobre esta política médica, debe comunicarse con Servicios para proveedores o Servicios para miembros de Capital Blue Cross.

Información de codificación

Nota: Esta lista de códigos no es exhaustiva y puede cambiar de vez en cuando según lo permita la ley o las pautas clínicas aplicables. La inclusión de un código en esta sección no constituye una garantía de cobertura o pago. Además, no todos los servicios cubiertos son elegibles para un reembolso por separado.

Cubierto cuando sea médicamente necesario:

*Note: 17999 can be used to code for laser hair removal of the donor site

Referencias

1. American College of Obstetricians and Gynecologists (ACOG). Healthcare for Transgender and Gender Diverse Individuals. Committee Opinion. Number 823, March 2021. Reaffirmed 2024.
2. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5TR; American Psychiatric Association, 2022).
3. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline [published correction appears in J Clin Endocrinol Metab. 2018 Feb 1;103(2):699] [published correction appears in J Clin Endocrinol Metab. 2018 Jul 1;103(7):2758-2759]. J Clin Endocrinol Metab. 2017; 102(11):3869-3903. Reaffirmed 2024. doi:10.1210/jc.2017-01658.
4. Landen M, Walinder J, Hambert G, Lundstrom B. Factors predictive of regret in sex reassignment. Acta Psychiatr Scand. 1998 Apr;97(4):284-289.
5. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003 Aug;32(4):299-315.
6. 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.
7. 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):3467-3473.
8. 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):472-481.
9. 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 306-308.
10. Tangpricha V, Safer JD. Transgender men: evaluation and management. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; actualizado el 27 de agosto de 2025. Literature review current through September 2025.
11. Tangpricha V, Safer JD. Transgender women: evaluation and management. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated October 12, 2023. Literature review current through September 2025.
12. 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;23(sup1):S1-S259. doi:10.1080/26895269.2022.2100644.
13. Wernick JA, Busa S, Matouk K, Nicholson J, Janssen A. A Systematic Review of the Psychological Benefits of Gender-Affirming Surgery. Urol Clin North Am. 2019;46(4):475-486. doi:10.1016/j.ucl.2019.07.002.
14. Olson-Kennedy J, Forcier M. Transgender and gender-diverse children and adolescents: Approach to gender-affirming care. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; actualizado el 28 de agosto de 2025. Literature review current through September 2025.
15. Ferrando C, Zhao L, Nikolavsky D. Gender-affirming surgery: Masculinizing procedures. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; actualizado el 26 de noviembre de 2024. Literature review current through September 2025.
16. Ferrando C. Gender-affirming surgery: Feminizing procedures. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated October 6, 2025. Literature review current through September 2025.
17. EncoderPro for Payers Professional. AMA CPT^® Section Guidelines – 19303

Antecedentes de la política

• MA 1.144
• 11/06/2025 Full adoption of commercial policy.

Plans issued by Capital Blue Cross and it's subsidiaries are independent licensees of the Blue Cross Blue Shield Association. Comunicaciones emitidas por Capital Blue Cross en su condición de administrador de programas y relaciones con los proveedores para todas las empresas.