Does 15121 require prior authorization?

No, 15121 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 15121?

Medicare facility rate: $119.24. Non-facility rate: $221.11. Work RVU: 1.95.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

1.95

Facility

$119.24

Non-Facility

$221.11

Documentation of a diagnosis of gender dysphoria or gender incongruence.
Clinical evidence demonstrating marked and sustained incongruence (meeting ≥2 Section A criteria), and documentation demonstrating that the member meets the eligibility criteria in Section B.
If procedures involve fertility preservation, follow policy CP.MP.130 (Fertility Preservation) as applicable.
A signed written statement from a qualified provider recommending gender-affirming medical or surgical treatment.

Hormone treatment for gender affirmation when medically necessary.
Counseling and psychotherapy to support gender-affirming care when clinically indicated.
Complete hysterectomy when medically necessary as part of gender-affirming surgical care.
Bilateral mastectomy or chest reconstruction/augmentation when medically necessary for gender affirmation.
Genital reconstruction procedures when medically necessary for gender affirmation.
Facial hair removal when medically necessary as part of gender-affirming treatment.

AMBETTER-CP.MP.95 — Gender-Affirming Procedures

Ask Verity about documentation requirements, denial risks, or coverage in your state.