19301
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
9.88
Facility
$632.61
Non-Facility
$632.61
Documentation Required
- Virginia: For regulated benefit plans (e.g., insured): Only one letter of support from a healthcare professional is required for gender affirming surgery for minors ages 15-17.
- Washington State: All services that might otherwise be excluded will be reviewed on a case-by-case basis by a medical director and a health care provider with experience prescribing or delivering gender affirming treatment who will confirm the appropriateness of any adverse benefit determination (i.e., case review by medical director and experienced provider is required for adverse determinations).
- Core needle biopsy or incisional biopsy pathology report documenting one of the listed diagnoses or findings
- No specific documentation requirements, required medical records, test results, or clinical documentation are stated in the provided excerpt.
Key Coverage Criteria
- Coverage for treatment of gender dysphoria, including gender reassignment surgery and related services (state-specific requirements apply).
- For Colorado regulated plans with Essential Health Benefits (EHB) (e.g., individual, non GF small group): the following feminization/masculinization procedures are classified as medically necessary for coverage under the EHB benefit plan effective 1/1/2023:
- Blepharoplasty (eye and lid modification).
- Face/forehead and/or neck tightening.
- Facial bone remodeling for facial feminization.
- Genioplasty (chin width reduction).
3 Active Policies
AMBETTER-CP.MP.31 — Cosmetic and Reconstructive Procedures
CIGNA-0266-STATE — Gender Dysphoria Treatment - State Guidelines
HUMANA-BREAST-EXCISION-AND-MASTECTOMY-MA — Breast Excision and Mastectomy - Medicare Advantage
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.