Does 40799 require prior authorization?

No, 40799 does not require prior authorization (low confidence). No active coverage policies found for this code.

What is the Medicare reimbursement rate for 40799?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Verity

`40799`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

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.
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.
For breast augmentation (age ≥18): 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

Treatment of gender dysphoria, including nonbinary individuals diagnosed with gender dysphoria.
Behavioral health services, including but not limited to, counseling for gender dysphoria and related psychiatric conditions (e.g., anxiety, depression).
Hormonal therapy, including but not limited to androgens, anti-androgens, GnRH analogues*, estrogens, and progestins (Prior authorization requirements may apply).
Laboratory testing to monitor prescribed hormonal therapy.
Age-related, gender-specific services, including but not limited to preventive health, as appropriate to the individual's biological anatomy (e.g., cancer screening [e.g., cervical, breast, prostate], treatment of a prostate medical condition).
Gender reassignment and related surgery when the policy's criteria for gender reassignment surgery are met.

1 Active Policy

CIGNA-0266 — Gender Dysphoria Treatment - (0266)

Have a follow-up question?

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

Mental health documentation for hormonal and/or surgery should be comprehensive and include: individual's general identifying characteristics; the initial and evolving gender, sexual and psychiatric diagnoses; details regarding the type and duration of psychotherapy or evaluation the individual received; the mental health professional's rationale for hormone therapy or surgery; the degree to which the individual has followed recommended medical management and likelihood of continued compliance; and whether or not the mental health professional is a part of a gender team.

40799