57107
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
23.95
Facility
$1321.01
Non-Facility
$1321.01
Documentation Required
- Documentation of a diagnosis of gender dysphoria or gender incongruence.
- Clinical evidence demonstrating marked and sustained incongruence (meeting ≥2 Section A criteria), and documentation demonstrating that the member meets the eligibility criteria in Section B.
- If procedures involve fertility preservation, follow policy CP.MP.130 (Fertility Preservation) as applicable.
- A signed written statement from a qualified provider recommending gender-affirming medical or surgical treatment.
Key Coverage Criteria
- Hormone treatment for gender affirmation when medically necessary.
- Counseling and psychotherapy to support gender-affirming care when clinically indicated.
- Complete hysterectomy when medically necessary as part of gender-affirming surgical care.
- Bilateral mastectomy or chest reconstruction/augmentation when medically necessary for gender affirmation.
- Genital reconstruction procedures when medically necessary for gender affirmation.
- Facial hair removal when medically necessary as part of gender-affirming treatment.
5 Active Policies
AMBETTER-CP.MP.95 — Gender-Affirming Procedures
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
BCBSNM-SUR717.001 — Gender Assignment Surgery and Gender Reassignment Surgery with Related Services
BCBSOK-SUR717.001 — Gender Assignment Surgery and Gender Reassignment Surgery with Related Services
Related Codes
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