All PlansCoverageMedium impact
Gender Affirming Interventions for Gender Dysphoria
Regence BlueShield·Plastic Surgery, Urology, OB-GYN +4 more·Medical Policy
Effective date
Apr 1, 2026
We identified it
Jun 16, 2026
Summary
New comprehensive medical policy MED153 establishes coverage criteria for gender affirming surgical interventions and procedures for gender dysphoria, effective April 1, 2026. The policy sets different requirements for contracts subject to Washington and Oregon state laws versus all other member contracts, with specific age requirements, documentation needs, and covered procedure lists.
Action Required
Before April 1, 2026: Billing team must implement new prior authorization and documentation requirements for all gender affirming procedures. Update billing system to flag gender dysphoria cases for medical necessity review including: licensed provider documentation, mental health diagnosis, 6-month hormone therapy history (except breast/chest surgery), and 6-month living in congruent role documentation. Configure different criteria paths for Washington/Oregon contracts versus other plans. Train staff on age requirements and covered procedure lists to ensure proper claim submission.