58260
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
13.80
Facility
$741.83
Non-Facility
$741.83
Documentation Required
- 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.
Key Coverage Criteria
- 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.
12 Active Policies
AMBETTER-CP.MP.95 — Gender-Affirming Procedures
AETNA-CPB-0512 — Premenstrual Syndrome and Premenstrual Dysphoric Disorder
A53793 — Billing and Coding: Sex Reassignment Services for Sexual Identity Dysphoria
UHC-POL-hysterectomy — Hysterectomy
UMR-POL-UMR-hysterectomy — Hysterectomy
Related Codes
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