Billing and Coding: Sex Reassignment Services for Sexual Identity Dysphoria

Cross-sex hormone therapy is covered for adults (age ≥18) with persistent, well-documented sexual identity dysphoria who can consent and have reasonably controlled medical/mental health concerns, after psychosocial assessment and informed consent. Sex reassignment surgery may be medically necessary only when all required criteria are met, including age ≥18, an individualized treatment plan, DSM-5 diagnosis with ≥6 months duration and requisite manifestations, clinically significant impairment, documented 12-month psychotherapy, 12-month full-time real-life experience, and (unless contraindicated) 12 months of cross-sex hormones; cosmetic-only procedures that do not improve physiologic function are not covered.

"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."