Medical Review Criteria

Gender Reassignment Services

Effective Date: May 12, 2016

Subject: Gender Reassignment Services for Fully-Insured Transgender Subscribers and Dependents

Policy:
HPHC covers specific Gender Reassignment Surgeries (GRS) and related clinician visits and medications that are
medically necessary and prescribed or recommended (by qualified practitioners) for eligible members (i.e.,
members enrolled in plans that include GRS benefits) diagnosed with Gender Dysphoria.1
Covered procedures must be performed by qualified providers trained in treating individuals with Gender
Dysphoria.
Members with questions about HPHCs GRS benefits and/or prior authorization processes should contact
HPHCs Member Services Department at 1-888-333-4742.

HPHC also covers retrieval, cryopreservation, and storage (up to one year) of sperm or eggs when documentation
confirms an eligible member with Gender Dysphoria will be undergoing Gender Reassignment treatment that is
likely to result in infertility.

Authorization:
Prior authorization is required for the following Gender Reassignment services:

For male to female transition: For female to male transition:

Augmentation Mammaplasty Colpectomy
Clitoroplasty Hysterectomy
Colovaginoplasty Mastectomy (bilateral)
Facial feminization procedures (coverage limited Metoidoplasty
to forehead contouring, mandible/jaw contouring, Phalloplasty
rhinoplasty and chondrolaryngoplasty) Rhinoplasty
Labiaplasty Salpingo-oophrectomy
Orchiectomy Scrotoplasy with placement of testicular
Penectomy prostheses
Rhinoplasty Urethroplasty
Vaginoplasty

Prior authorization is also required for retrieval, cryopreservation, and storage (up to one year) of sperm or eggs.

Criteria:
Gender Reassignment services are authorized when letters from clinicians (i.e. physician(s) and Mental Health
Professional) responsible for hormone therapies and/or other related transitional care confirm ALL the following2:
1. Member age 18 years or older has been diagnosed, by an appropriately trained Mental Health Professional3
(MHP), with Gender Dysphoria;
2. Member wishes to make his/her body as congruent as possible with the preferred gender through surgery
and hormone replacement;

1
Coverage includes treatment of medical complications related to authorized GRS surgeries.

2
HPHC requires at least two letters from treating clinicians. Members may provide these to support the authorization process.
3
Mental health services are administered by Optum dba United Behavioral Health (UBH). For questions about benefits and providers call 1-
866-808-5062.

HPHC Medical Review Criteria

Gender Reassignment Surgery Page 1 of 6

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please
reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.
3. GRS has been recommended by treating physician(s) and MHP;
4. The physician has medically cleared the individual for GRS.

Retrieval, cryopreservation, and storage (up to one year) of sperm or eggs (as appropriate) is authorized when
documentation confirms the member with Gender Dysphoria will be undergoing Gender Reassignment treatment
that is likely to result in infertility. (The member is not required to meet HPHCs criteria for Infertility Services but
the plan must include infertility benefits.)
Documentation must confirm that member and provider(s) have discussed the impact of Gender
Reassignment treatment on fertility and family planning

Exclusions:
HPHC does not cover Gender Reassignment services when criteria above are not met.

HPHC does not cover the following procedures when performed for the purpose of gender reassignment:
Blepharoplasty
Collagen injections
Electrolysis
Face-lifting of any kind (i.e. rhytidectomy)
Facial implants or injections
Hair removal
Hair transplantation
Laryngoplasty
Lip reduction/enhancement
Liposuction
Removal of redundant skin
Silicone injections (e.g., for breast enlargement)
Voice modification surgery

In addition, HPHC does not cover or reimburse for travel expenses incurred in relation to GRS

Related Codes: Code lists may not include all GRS-related services.

Male to Female Transition Accepted Coding

Gender Reassignment Surgery 55970 Intersex surgery, male to female
Facial Feminization Surgery 21209 Osteoplasty, facial bones; reduction
21120 Genioplasty, augmentation (autograft, allograft, prosthetic
implant)
21121 Genioplasty; sliding osteotomy, single piece
21122 Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g.
wedge excision or bone wedge reversal of asymmetrical chin)
21123 Genioplasty; sliding, augmentation with interpositional bone
grafts (including obtaining autografts)
21125 Augmentation, mandibular body or angle; prosthetic material
21127 Augmentation, mandibular body or angle, with bone graft, onlay
or interpostitional (includes obtaining autograft)
21137 Reduction forehead; contouring only
21138 Reduction forehead; contouring and application of prosthetic
material or bone graft (includes obtaining autograft)
21139 Reduction forehead; contouring and setback of anterior frontal
sinus wall

HPHC Medical Review Criteria

Gender Reassignment Surgery Page 2 of 6

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please
reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.
 Male to Female Transition Accepted Coding
30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation
of nasal tip
30401 Rhinoplasty, primary; complete, external parts including bony
pyramid, lateral and alar cartilages and/or elevation of nasal tip
30420 Rhinoplasty, primary; including major septal repair
30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip
work)
30435 Rhinoplasty, secondary; intermediate revision (bony work with
osteotomies)
30450 Rhinoplasty, secondary; major revision (nasal tip work and
osteotomies)
Trachea shaving 31750 Tracheoplasty; cervical
31587 Laryngoplasty, cricoid split
Penectomy and related 54120 Amputation of penis; partial
procedures 54125 Amputation of penis; complete
53415 Urethroplasty, transpubic or perineal, 1-stage, for reconstruction
or repair of prostatic or membranous urethra
53420 Urethroplasty, 2-stage reconstruction or repair off prostatic or
membranous urethra; first stage
53425 - Urethroplasty, 2-stage reconstruction or repair off prostatic or
membranous urethra; second stage
53430 Urethroplasty, reconstruction of female urethra
Orchiectomy 54520 Orchiectomy, simple (including subcapsular), with or without
testicular prosthesis, scrotal or inguinal approach
54690 Laparoscopy, surgical; orchiectomy
55586 Laparoscopy, surgical prostatectomy, retropubic radical, including
nerve sparing, includes robotic assistance, when performed
Vaginoplasty 56800 Plastic repair of introitus
57291 Construction of artificial vagina; without graft
57292 Construction of artificial vagina; with graft
57295 Revision (including removal) of prosthetic vaginal graft; vaginal
approach
57296 Revision (including removal) of prosthetic vaginal graft; open
abdominal approach
57335 Vaginoplasty for intersex state
57426 Revision (including removal) of prosthetic vaginal graft,
laparoscopic approach
Labiaplasty 14301 Adjacent tissue transfer or rearrangement, any area; defect 30.1
sq cm to 60.0 sq cm
56800 Plastic repair of introitus
58999 - Unlisted procedure, female genital system (nonobstetrical)**
Clitoroplasty 56805 Clitoroplasty for intersex state (female procedure)
Breast Augmentation 19324 Mammaplasty, augmentation; without prosthetic implant
19325 Mammaplasty, augmentation, with prosthetic implant
19350 Nipple/areola reconstruction
19357 Breast reconstruction, immediate or delayed, with tissue
expander, including subsequent expansion
19380 Revision of reconstructed breast

Female to Male Transition Accepted Coding

Gender Reassignment Surgery 55980 Intersex surgery, female to male
HPHC Medical Review Criteria

Gender Reassignment Surgery Page 3 of 6

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please
reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.
 Female to Male Transition Accepted Coding
Mastectomy 19303 Mastectomy, simple, complete
19304 Mastectomy, subcutaneous
19350 Nipple/areola reconstruction
Hysterectomy and related 56625 Vulvectomy simple; complete
procedures 56810 Perineoplasty, repair of perineum, nonobstetrical
57106 Vaginectomy, partial removal of vaginal wall
57110 Vaginectomy, complete removal of vaginal wall
58150 Total abdominal hysterectomy (corpus and cervix), with or
without removal of tube(s), with or without removal of ovary(s)
58180 Supracervical abdominal hysterectomy (subtotal hysterectomy),
with or without removal of tube(s), with or with removal of
ovary(s)
58260 Vaginal hysterectomy, for uterus 250 grams or less;
58262 Vaginal hysterectomy, for uterus 250 grams or less, with removal
of
58275 Vaginal hysterectomy, with total or partial vaginectomy;
58290 Vaginal hysterectomy, for uterus greater than 250 g;
58291 Vaginal hysterectomy, for uterus greater than 250 g; with
removal of tube(s) and/or ovary(s)
58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus
250 g or less;
58542 Laparoscopy, surgical, supracervical hysterectomy, for uterus
250 g or less; with removal of tube(s) and/or ovary(s)
58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus
greater than 250 g;
58544 Laparoscopy, surgical, supracervical hysterectomy, for uterus
greater than 250 g; with removal of tube(s) and/or ovary(s)
58550 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250
g or less;
58552 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250
g or less; with removal of tube(s) and/or ovary(s)
58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus
greater than 250 g;
58554 Laparoscopy, surgical, with vaginal hysterectomy, for uterus
greater than 250 g; with removal of tube(s) and/or ovary(s)
58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g
or less;
58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g
or less; with removal of tube(s) and/or ovary(s)
58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater
than 250 g;
58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater
than 250 g; with removal of tube(s) and/or ovary(s)
58661 Laparoscopy, surgical; with lysis of adhesions (salpingolysis,
ovariolysis) (separate procedure): with removal of adnexal
structures (partial or total oophorectomy and/or salpingectomy
58720 Salpingo-oophorectomy, complete or partial, unilateral or
bilateral (separate procedure)
58940 Oophorectomy, partial or total, unilateral or bilateral
Metoidioplasty 55899 Unlisted procedure; male genital system**

HPHC Medical Review Criteria

Gender Reassignment Surgery Page 4 of 6

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please
reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.
 Female to Male Transition Accepted Coding
Phalloplasty and related 53415 Urethroplasty, transpubic or perineal, 1-stage, for reconstruction
procedures or repair of prostatic or membranous urethra
53420 Urethroplasty, 2-stage reconstruction or repair off prostatic or
membranous urethra; first stage
53425 - Urethroplasty, 2-stage reconstruction or repair off prostatic or
membranous urethra; second stage
53430 Urethroplasty, reconstruction of female urethra
54400 Insertion of penile prosthesis; noninflatable (semi-rigid)
54401 Insertion of penile prosthesis; inflatable (self-contained)
54405 Insertion of multi-component inflatable penile prosthesis,
including placement of pump, cylinders and reservoir
54660 Insertion of testicular prosthesis (separate procedure)
55175 Scrotoplasty; simple
55180 Scrotoplasty; complicated
55899 Unlisted procedure; male genital system**
Rhinoplasty 30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation
of nasal tip
30401 Rhinoplasty, primary; complete, external parts including bony
pyramid, lateral and alar cartilages and/or elevation of nasal tip
39420 Rhinoplasty, primary; including major septal repair
30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip
work)
30435 Rhinoplasty, secondary; intermediate revision (bony work with
osteotomies)
30450 Rhinoplasty, secondary; major revision (nasal tip work and
osteotomies

Additional Procedures Accepted Codes

Tissues expansion 11960 Insertion of tissue expanders(s) for other than breast, including
subsequent expansion
11970 Replacement of tissue expander with permanent prosthesis
11971 Removal of tissue expander(s) without insertion of prosthesis
14040 Adjacent tissue transfer or rearrangement, forehead, cheeks,
chin, mouth, axillae, genitalia, hands, and/or feet; defect 10
sq.cm or less
14041 Adjacent tissue transfer or rearrangement, forehead, cheeks,
chin mouth, neck, axillae, genitalia, hands, and/or feet; defect
10.1 sq. cm to 30 sq. cm

** Procedures billed with an unlisted code pend for medical review; additional documentation must
accompany submitted claim.

Revision History:
Approved by UMCPC: 6/28/17
Revised: 7/14; 2/15; 4/15; 11/15; 4/16
Initiated: 2013

Date Summary of Changes

6/17 Reissued
3/16 Clarified documentation requirements. Corrected coding.
11/15 Updated policy language
HPHC Medical Review Criteria

Gender Reassignment Surgery Page 5 of 6

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please
reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.
 2/15 Clarified coding, updated policy language. Added language re: coverage of retrieval,
cryopreservation and storage of sperm or eggs.

References:
WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People,
Seventh Version: http://www.wpath.org/

HPHC Medical Review Criteria

Gender Reassignment Surgery Page 6 of 6

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please
reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.