ICD-10 F64.1 is officially defined as "Dual role transvestism." code F64.1 is referenced in 4 tracked payer policy changes from Nevada Medicaid, Kansas Medicaid (KanCare), and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code F64.1 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Nevada Medicaid now requires prior authorization for specific gender dysphoria surgical procedures when billed with certain diagnosis codes (F64.0, F64.1, F64.2, F64.8, F64.9, or Z87.890). Six specific procedure codes are affected, and modifier KX or condition code 45 is still required for transgender patient claims.
Kansas Medicaid will no longer cover new surgical or hormonal gender affirming care for adults 21 and older starting September 1, 2025. Claims with gender dysphoria diagnosis codes will automatically suspend for manual review to check for grandfathered exceptions.
Aetna considers voice therapy medically necessary to restore the ability to produce speech sounds from the larynx for essential voice tremor, surgery or traumatic injury to the vocal cords, treatment for laryngeal (glottic) carcinoma, muscle tension dysphonia, paradoxical vocal cord motion, post-laryngectomy esophageal speech production, spastic dysphonia, symptomatic benign vocal fold lesions, and vocal cord paralysis. Voice therapy is not medically necessary to improve voice quality, for occupational or recreational purposes, or for self-limited conditions such as acute laryngitis, and maintenance treatment where symptoms are not improving is not medically necessary. Pre-operative voice therapy for improving outcomes of surgery for benign vocal fold lesions, and voice therapy for vocal fold motion impairment following chemotherapy, are considered experimental, investigational, or unproven.
Aetna considers endometrial ablation medically necessary for women with menorrhagia that is unresponsive to, or has a contraindication to, either dilation and curettage or hormonal therapy, when the severity and persistence of the bleeding would otherwise make the member a candidate for hysterectomy. The selection criteria also require that endometrial sampling or D&C was performed on the same day or within the year before the procedure to exclude cancer, pre-cancer or hyperplasia, that structural abnormalities requiring surgery were excluded, and that a Pap smear and gynecologic examination excluded significant cervical disease. Aetna considers endometrial ablation experimental, investigational, or unproven for all other indications, such as post-menopausal bleeding.
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