15200
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
8.92
Facility
$605.22
Non-Facility
$875.77
Documentation Required
- For adolescents, documentation that qualified health professionals experienced in child/adolescent mental health and gender identity have evaluated the patient and assessed capacity to assent/consent, and that clinicians have considered developmental and neurodiversity issues where relevant.
- Documentation of prior treatments when relevant (e.g., record of puberty suppression, duration and type of hormone therapy — e.g., minimum 6 months of feminizing hormones prior to breast augmentation when applicable).
- Surgeon credentials and documentation of training and documented supervision in gender‑affirming procedures, maintenance of an active practice in gender‑affirming procedures, continuing education in gender‑affirmation surgery, knowledge about gender diverse identities and expressions, and tracking of surgical outcomes (as listed under WPATH SOC‑8).
Key Coverage Criteria
- Gender‑affirming hormone therapy (including puberty suppression with GnRH agonists in adolescents and cross‑sex hormones for adolescents and adults) when clinically indicated for gender dysphoria.
- Aetna considers gender affirming surgery medically necessary when criteria for each of the following procedures is met:
- Requirements for Breast Removal: Signed letter from a qualified mental health professional (see Appendix) assessing the transgender/gender diverse individual’s readiness for physical treatment; and Documentation of marked and sustained gender dysphoria (see Appendix); and Other possible causes of apparent gender incongruence have been excluded; and Mental and physical health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and be [...]
- Select CPT/HCPCS codes are covered if selection criteria are met (see policy code tables). Examples include procedures for reconstruction, grafting/flap procedures, penile and testicular prostheses, hysterectomy/oophorectomy codes, urethroplasty codes, vaginoplasty/vaginectomy codes, tissue expander placement for breast reconstruction, and specific HCPCS prosthesis/drug codes listed in the CPB.
- Gender dysphoria as defined by DSM‑5: a marked incongruence between one’s experienced/expressed gender and assigned gender of at least 6 months' duration, manifested by two or more DSM‑5 criteria, and associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- Evaluation of candidacy for gender affirmation surgery by a mental health professional (evaluation is covered under the member's medical benefit unless services are necessary to treat a mental health problem).
3 Active Policies
AMBETTER-CP.MP.95 — Gender-Affirming Procedures
CIGNA-0266-STATE — Gender Dysphoria Treatment - State Guidelines
AETNA-CPB-0615 — Gender Affirming Surgery
Related Codes
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