Gender Affirming Surgery (CPB 0615, reviewed 2026-09-08)

Immediately: Billing and prior authorization teams must implement the following: (1) Update billing system to require documented proof of mental health evaluation letter before processing claims for all gender affirming surgery CPT codes listed; (2) Configure system to enforce hormone therapy duration requirements (6 months standard adult, 12 months for adolescents <18, with medical contraindication exceptions) for gonadectomy and genital reconstructive surgery; (3) Create pre-authorization checklist requiring: signed mental health professional letter, documentation of marked/sustained gender dysphoria, exclusion of other causes of gender incongruence, mental/physical health assessment, and capacity to consent; (4) For breast augmentation specifically, verify 6 months feminizing hormone therapy (12 months for adolescents) prior to authorization; (5) For breast removal in adolescents <18, verify 1 year testosterone treatment unless medically contraindicated; (6) Flag and deny claims for excluded procedures: hair removal (except limited sessions for genital surgery skin graft prep), tracheal shave, facial gender affirming procedures, body contouring, and multiple breast augmentations; (7) Update encounter forms and authorization templates to capture required documentation fields. Failure to implement these requirements will result in claim denials and member appeals. Ensure providers understand that some plan-specific variations may exist per benefit documents.