Does 55175 require prior authorization?

No, 55175 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 55175?

Medicare facility rate: $339.69. Non-facility rate: $339.69. Work RVU: 5.72.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

5.72

Facility

$339.69

Non-Facility

$339.69

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.

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.

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

A53793 — Billing and Coding: Sex Reassignment Services for Sexual Identity Dysphoria

HUMANA-GENDER-AFFIRMATION-SURGERY-MA — Gender Affirmation Surgery - Medicare Advantage

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

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

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