Medical policy: Gender Affirming Surgery

Policy number: MP 1.144

Effective date: 4/1/2026

Policy

Gender affirming surgery may be considered medically necessary when all of the following pre-procedure criteria are met:

• Recommendation for surgical intervention by one qualified health care professional
  • A qualified health care professional, for purposes of this policy, is usually a licensed behavioral health care professional who holds a postgraduate degree. Other health care professionals who can document achievement of WPATH competencies can be considered; and
  • The recommendation letter should include a comprehensive evaluation/report (comprehensive biopsychosocial assessment for adolescents) that documents all of the following:
    • Marked and sustained gender incongruence or gender dysphoria (see Appendix); and
    • The individual has the capacity to make a fully informed decision and to consent for treatment; and
    • Other possible causes of apparent gender incongruence have been identified and excluded; and
    • Mental and physical health conditions that could negatively impact the outcome of gender affirming medical treatments are assessed, with risks and benefits discussed.
• Documentation of at least 6 months of continuous hormonal therapy as appropriate to the individual’s gender goals (unless medically contraindicated or hormone therapy is not desired).
  • Adolescents must have documentation of 12 months of continuous hormonal therapy as appropriate to the individual’s gender goals (unless medically contraindicated or hormone therapy is not desired).

Female to male or gender diverse transition

When all of the pre-procedure criteria are met, the following breast and genital surgeries may be considered medically necessary for transmen or those that are gender diverse:

• Breast reconstruction (e.g., reduction mammoplasty)
• Hysterectomy
• Metoidioplasty
• Penile prosthesis insertion
• Phalloplasty
• Salpingo-oophorectomy
• Scrotoplasty
• Testicular prosthesis implantation
• Urethroplasty
• Vaginectomy
• Vulvectomy, simple, complete

Male to female or gender diverse transition

When all of the pre-procedure criteria are met, the following breast and genital surgeries may be considered medically necessary for transwomen or those that are gender diverse:

• Breast augmentation
• Colovaginoplasty
• Clitoroplasty
• Labiaplasty
• Orchiectomy
• Penectomy
• Vulvoplasty
• Vaginoplasty

Other gender affirming interventions

When all of the pre-procedure criteria are met, the following procedures may be considered medically necessary when the intervention is expected to effectively treat the individual’s gender incongruence and/or dysphoria (this list may not be all-inclusive):

• Abdominoplasty
• Blepharoplasty
• Blepharoptosis
• Brow lift
• Calf augmentation/implants
• Cheek/malar implants
• Chin augmentation
• Collagen injections
• Cricothyroid approximation
• Dermabrasion/Skin resurfacing
• Facial feminizing/sculpturing (e.g., jaw shortening, forehead reduction)
• Forehead lift
• Hair removal – Electrolysis or laser hair removal
• Hair transplantation
• Laryngoplasty
• Lip reduction/enhancement
• Liposuction
• Mastopexy
• Nose implants
• Removal of redundant skin
• Rhinoplasty
• Rhytidectomy
• Scrotoplasty
• Trachea shave/reduction thyroid chondroplasty
• Voice modification surgery
• Voice therapy/voice lessons

Note: Additional procedures may be available based on an individual’s benefit.

Detransition, to include surgical intervention, may be considered medically necessary when all of the following criteria have been met:

• The individual is being cared for by a comprehensive multidisciplinary assessment team; and
• Social transition has been discussed and considered; and
• The individual has lived in the social role for a prolonged period of time (if recommended by the multidisciplinary team); and
• The assessing health care professional, who is a member of the comprehensive multidisciplinary assessment team, documents how detransition is in the best interest of the individual.

Cross-references

• MP 1.004 Cosmetic and Reconstructive Surgery
• MP 2.345 Subcutaneous Hormone Pellet Implants

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP Medical Policy Manual.

Description/background

Gender incongruence is defined as a condition in which the gender identity of a person does not align with the gender assigned at birth. Gender dysphoria refers to the psychological distress that results from incongruence between one’s sex assigned at birth and one’s gender identity. Though gender dysphoria often begins in childhood, some people may not experience it until after puberty or much later.

Transgender and gender diverse (TGD) is a broad and comprehensive term that describes members of the many varied communities that exist globally of people with gender identities or expressions that differ from the gender socially attributed to the sex assigned to them at birth.

The goal of gender-affirming care is to partner with TGD people to holistically address their social, mental, and medical health needs and well-being while respectfully affirming their gender identity. Gender-affirming interventions include puberty suppression, hormone therapy, and gender-affirming surgeries among others. It should be emphasized there is no “one-size-fits-all” approach and TGD people may need to undergo all, some, or none of these interventions to support their gender affirmation.

Gender affirming surgery is intended to be a permanent change, establishing congruency between an individual’s gender identity and physical appearance and is not easily reversible. The choice to detransition is proportionally rare.

The American Medical Association (AMA) and the American Academy of Professional Coders (AAPC) gives guidance on coding reduction mammoplasty for gender affirmation. Per AMA, CPT code 19303 (mastectomy) is to be used for the treatment or prevention of breast cancer. AMA Section Guidelines state “when breast tissue is removed for breast-size reduction and not for treatment or prevention of breast cancer, report 19318 (reduction mammoplasty).”

Rationale

Professional society/organization

World Professional Association for Transgender Health (WPATH) Guidelines: “There is strong evidence demonstrating the benefits in quality of life and well-being of gender-affirming treatments, including endocrine and surgical procedures, when provided and performed as outlined by the Standards of Care (Version 8). In TGD people in need of these treatments, gender-affirming interventions may also include hair removal/transplant procedures, voice therapy/surgery, counseling, and other medical procedures required to effectively affirm an individual’s gender identity and reduce gender incongruence and dysphoria. Gender-affirming interventions are based on decades of clinical experience and research; therefore, they are not considered experimental, cosmetic, or for the mere convenience of a patient. They are safe and effective at reducing gender incongruence and gender dysphoria.”

Definitions

Adolescent refers to the start of puberty until the legal age of majority.

Gender diverse - Per WPATH, gender diverse individuals have often been neglected and/or marginalized and include nonbinary, eunuch, and intersex individuals.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the member’s benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Covered when medically necessary

*Note: 17999 can be used to code for laser hair removal of the donor site

References

1. American College of Obstetricians and Gynecologists (ACOG). Healthcare for Transgender and Gender Diverse Individuals. Committee Opinion. Number 823, March 2021. Reaffirmed 2024.
2. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5TR). American Psychiatric Association, 2022.
3. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline [published correction appears in J Clin Endocrinol Metab. 2018 Feb 1;103(2):699] [published correction appears in J Clin Endocrinol Metab. 2017;102(11):3869-3903. Reaffirmed 2024. doi:10.1210/jc.2017-01658.
4. Landen M, Walinder J, Hambert G, Lundstrom B. Factors predictive of regret in sex reassignment. Acta Psychiatr Scand. 1998 Apr;97(4):284-9.
5. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003 Aug;32(4):299-315.
6. Maharaj NR, Dhai A, Weeraman R, Moodley J. Intersex conditions in children and adolescents: surgical, ethical, and legal considerations. J Pediatr Adolesc Gynecol. 2005 Dec;18(6):399-402.
7. Moore E, Wisniewski A, Dobs A. Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects. J Clin Endocrinol Metab. 2003 Aug;88(8):3467-73.
8. Smith YL, van Goozen SH, Cohen-Kettenis PT. Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study. J Am Acad Child Adolesc Psychiatry. 2001 Apr;40(4):472-81.
9. Sutcliffe PA, Dixon S, Akehurst RL, Wilkinson SN, Shippam A, White S. A systematic review of satisfaction and regret following gender reassignment surgery. J Plast Reconstr Aesthet Surg. 2009 Mar;62(3):306-8.
10. Tangpricha V, Safer JD. Transgender men: evaluation and management. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated August 27, 2025. Literature review current through September 2025.
11. Tangpricha V, Safer JD. Transgender women: evaluation and management. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated October 12, 2023. Literature review current through September 2025.
12. Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health. 2022;23(sup1):S1–S259. DOI: 10.1080/26895269.2022.2100644.
13. Wernick A, Busa S, Mautuk K, Nicholson J, Larsen A. A Systematic Review of the Psychological Benefits of Gender-Affirming Surgery. Urol Clin North Am. 2019;46(4):475-486. doi:10.1016/j.ucl.2019.07.002.
14. Olson-Kennedy J, Forcier M. Transgender and gender-diverse children and adolescents: Approach to gender-affirming care. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated August 28, 2025. Literature review current through September 2025.
15. Ferrando C, Zhao L, Nikolavsky D. Gender-affirming surgery: Masculinizing procedures. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated November 26, 2024. Literature review current through September 2025.
16. Ferrando C. Gender-affirming surgery: Feminizing procedures. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated October 6, 2025. Literature review current through September 2025.
17. EncoderPro for Payers Professional. AMA CPT^® Section Guidelines – 19303.