Does 19303 require prior authorization?

Yes, 19303 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 19303?

Medicare facility rate: $915.85. Non-facility rate: $915.85. Work RVU: 14.63.

Verity

`19303`

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

14.63

Facility

$915.85

Non-Facility

$915.85

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).
For initial mastectomy (≥ age 17): one letter of support from a qualified mental health professional who has evaluated the individual for gender dysphoria and gives unequivocal support for the procedure being proposed.

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).

6 Active Policies

AMBETTER-CP.MP.31 — Cosmetic and Reconstructive Procedures

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

SUR717.001 — Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

CIGNA-0266-STATE — Gender Dysphoria Treatment - State Guidelines

CIGNA-0266 — Gender Dysphoria Treatment - (0266)

Have a follow-up question?

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

For initial mastectomy (age 15 to <17): parental/guardian consent (when applicable) AND two separate letters of support, each from an independent mental health provider experienced in adolescent mental health and the diagnosis and treatment of childhood gender dysphoria; each mental health evaluation must confirm a diagnosis of gender dysphoria, confirm it is marked and sustained over time (e.g., two years), address any mental health comorbidities, and document the individual's emotional and cognitive maturity necessary to provide informed consent.

19303