15878
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- Medical records must document an extensive psychosocial evaluation exploring psychological, family, and social issues prior to and after cross-sex hormone therapy or surgery.
- Documented informed consent is required for cross-sex hormone therapy, including evidence that benefits and risks were explained and understood.
- A sex reassignment treatment plan specific to the individual beneficiary must be created and documented for surgical consideration.
- One letter from a mental health professional is required verifying at minimum 12 months of psychotherapy and attesting that psychiatric/medical comorbidities are stable and the patient is prepared for surgery.
- Documentation that the individual completed 12 months of continuous, full-time, real-life experience in the desired sex must be included.
- Unless contraindicated, documentation of 12 consecutive months of responsible cross-sex hormone therapy (including screenings and follow-ups) must be provided for surgical eligibility.
Key Coverage Criteria
- Initiation of cross-sex hormone therapy is covered after a psychosocial assessment and documented informed consent when the member has persistent, well-documented sexual identity dysphoria.
- Member must have capacity to make a fully informed decision and provide consent to receive cross-sex hormone therapy.
- Member must be at least 18 years of age to receive cross-sex hormone therapy or sex reassignment surgery.
- Cross-sex hormone therapy may be provided when significant medical or mental health concerns, if present, are reasonably well controlled (co-existing concerns do not automatically preclude therapy).
- Sex reassignment surgery may be considered medically necessary only when ALL required criteria are met, including age ≥18, an individualized sex reassignment treatment plan, a documented DSM-5 diagnosis of sexual identity dysphoria with at least 6 months duration and ≥2 required manifestations, and associated clinically significant distress or impairment.
- One letter from a mental health professional documenting a minimum of 12 months of psychotherapy is required, attesting that co-morbid psychiatric/medical conditions are stable and the individual is prepared to undergo surgery and has persistent chronic sexual identity dysphoria.
20 Active Policies
L39051 — Cosmetic and Reconstructive Surgery
J05
A58774 — Billing and Coding: Cosmetic and Reconstructive Surgery
J05
CGS-L39506 — Cosmetic and Reconstructive Surgery
J18 MAC Part B
WPS-L39051 — Cosmetic and Reconstructive Surgery
J8 MAC Part B
NORIDIAN-L35163 — Plastic Surgery
JF Part B
N/A — N/A
JJ Part B
PALMETTO-N/A — N/A
JJ Part B
A57221 — Billing and Coding: Plastic Surgery
A53793 — Billing and Coding: Sex Reassignment Services for Sexual Identity Dysphoria
AMBETTER-CP.MP.62 — Hyperhidrosis Treatments
L39506 — Cosmetic and Reconstructive Surgery
UHC-POL-liposuction-lipedema — Liposuction for Lipedema
UHC-POL-panniculectomy-body-contouring-procedures — Panniculectomy Surgery
UHC-POL-surgical-treatment-lymphedema — Surgery for the Prevention and Treatment of Lymphedema
SUREST-POL-SUREST-panniculectomy-body-contouring-procedures — Panniculectomy Surgery
L35163 — Plastic Surgery
SUREST-POL-SUREST-liposuction-lipedema — Liposuction for Lipedema
UMR-POL-UMR-surgical-treatment-lymphedema — Surgery for the Prevention and Treatment of Lymphedema
A59299 — Billing and Coding: Cosmetic and Reconstructive Surgery
UMR-POL-UMR-panniculectomy-body-contouring-procedures — Panniculectomy Surgery
Related Codes
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