Highmark Commercial Medical Policy - Pennsylvania

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Medical Policy: S-184-008
Topic: Gender Reassignment Surgery
Section: Surgery
Effective Date: March 5, 2018
Issue Date: March 5, 2018
Last Reviewed: October 2016

Gender reassignment surgery (GRS), either as a male-to-female (MTF) transition or as a female-to-male (FTM) transition, consists of medical and surgical treatments that change primary sex characteristics for individuals with gender dysphoria or gender identity disorder who wish to make a permanent transition.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

GRS may be considered medically necessary when ALL of the following are met:

  • The individual is greater than or equal to 18 years of age; and
  • The individual has the capacity to make a fully informed decision and to consent for treatment; and  
  • The individual has been diagnosed with the gender dysphoria of transsexualism, including ALL of the following:
    • The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
    • The individual's transsexual identity has been present persistently for at least two (2) years; and
    • The disorder is not a symptom of another mental disorder or a chromosomal abnormality; and
    • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The individual is an active participant in a recognized gender identity treatment program and demonstrates ALL of the following conditions:
    • The individual has successfully lived and worked within the desired gender role full-time for at least 12 months (real life experience) without returning to the original gender; and
    • Initiation of hormonal therapy or breast surgery recommended by a qualified health professional with written documentation submitted to the physician responsible for the medical treatment; and
    • Documentation of at least 12 months of continuous hormonal sex reassignment therapy, unless medically contraindicated (may be simultaneous with real life experience); and
    • Recommendation for sex reassignment surgery by two (2) qualified mental health professionals who recommend sex reassignment surgery with written documentation submitted to the physician performing the genital surgery*; and
    • Separate evaluation by the physician performing the genital surgery.

* At least one (1) letter must be a comprehensive report. Two (2) separate letters or one (1) letter with two (2) signatures is acceptable. One (1) letter from a Master’s degree mental health professional is acceptable if the second letter is from a psychiatrist or Ph.D. (clinical psychologist).

Procedure Codes
55970, 55980

When ALL of the above criteria are met, the following breast/genital surgeries may be considered medically necessary for the following indications:


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

Note: Although not a requirement, it is recommended that MTF undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.


  • Breast reconstruction (e.g., mastectomy)
  • Colpectomy/Vaginectomy
  • Hysterectomy
  • Metoidioplasty
  • Penile prosthesis
  • Phalloplasty
  • Reduction mammoplasty
  • Salpingo-oophorectomy
  • Scrotoplasty
  • Testicular prosthesis implantation
  • Urethroplasty

Note: Penile prosthesis surgery is typically performed at stage two (2) or three (3) of a multi-stage phalloplasty (a minimum of nine (9) months following stage one (1)).

Procedure Codes
19303, 19304, 19318, 19324, 19325, 53430, 54125, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54520, 54660, 54690, 55175, 55180, 55899, 56805, 57110, 57291, 57292, 57335, 58150, 58262, 58552, 58554, 58571, 58573, 58661, 58999

The following procedures that may be performed as a component of a gender reassignment are considered cosmetic and, therefore, non-covered (this is not an all-inclusive list):

  • Blepharoplasty
  • Blepharoptosis 
  • Chin augmentation 
  • Collagen injections
  • Cricothyroid approximation
  • Facial bone reduction-facial feminizing
  • Hair removal – electrolysisor laser hair removal
  • Hair transplantation
  • Laryngoplasty
  • Lip reduction/enhancement
  • Liposuction
  • Mastopexy
  • Nipple/areola reconstruction
  • Removal of redundant skin
  • Rhinoplasty
  • Rhytidectomy
  • Trachea shave/reduction thyroid chondroplasty
Procedure Codes
11950, 11951, 11952, 11954, 15775, 15776, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15829, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15879, 17380, 17999, 19316, 19350, 21120, 21121, 21122, 21123, 21209, 21225, 21227, 21899, 30400, 30410, 30420, 30430, 30435, 30450, 31599, 31899, 40799, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909

Preventive Medicine GRS

Please refer to the member specific benefit plan for screenings (e.g., mammogram, routine gynecological examination, pap smear).

Preventive services are subject to the terms of the member’s individual or group customer benefit

Refer to medical policy S-28 Cosmetic Surgery vs. Reconstructive Surgery for additional information.

Place of Service: Inpatient/Outpatient

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

A network provider can bill the member for the cosmetic service.

A network provider cannot bill the member for the non-covered service.

Outpatient HCPCS (C Codes)

C1813 C2622    


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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