CommercialPrior AuthMedium impact
21-793 Medical Necessity Criteria for Treatment of Gender Dysphoria
Health Net·CA · Endocrinology, Psychiatry, Plastic Surgery +2 more·Prior Authorization
Effective date
Jan 1, 2021
We identified it
Jun 20, 2026
Summary
Health Net now requires Participating Physician Groups (PPGs) to use WPATH Standards of Care criteria for determining medical necessity of gender dysphoria treatments, effective January 1, 2021. PPGs must incorporate these nonprofit clinical guidelines into their utilization management decision-making hierarchy and document this in their policies.
Action Required
Immediately: PPGs delegated for utilization management must update their medical necessity determination policies to include WPATH Standards of Care criteria for gender dysphoria treatments. Document the decision-making hierarchy that incorporates these guidelines. Access the criteria through the Health Net provider portal under Resources > Medical Policies. Await training communications from Health Net regarding WPATH guidelines implementation.