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Medical Policy Revision: Gender Reassignment Surgery

Effective May 1, 2019, Horizon BCBSNJ will change the way we consider certain professional claims based on revisions to our medical policy, Gender Reassignment Surgery.

Access our Medical Policy Manual to review this medical policy content.¹


Claims submitted for services provided on and after May 1, 2019 to patients enrolled in Horizon BCBSNJ commercial, Administrative Services Only (ASO), or Medicare Advantage (MA) plans will be processed as follows.

  • Regardless of the submitted diagnosis code(s), information will be requested to help us determine the medical appropriateness of the services represented by CPT® codes 15786, +15787, 15824, 15825, 15826, 15828, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15878, 15879 or 17380.
     
  • Following our review, the services represented by these codes may be denied as cosmetic services.
     
  • Based on the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by CPT codes 11970, 11971, 15871, 92507 and/or 92508.
     
  • Following our review, the services represented by these codes may be denied as not medically necessary or cosmetic services.
     
  • Based on the submitted diagnosis code(s), CPT codes 92507 or 92508 may be denied as cosmetic services.

Claims submitted for services provided on and after May 1, 2019 to patients enrolled in Horizon BCBSNJ commercial or ASO plans will be processed as follows.

  • Regardless of the submitted diagnosis code(s), information will be requested to help us determine the medical appropriateness of the services represented by CPT codes 11950, 11951, 11952, 11954, 15775, 15776, 15780, 15781, 15782 or 15783.
  • Following our review, the services represented by these codes may be denied as cosmetic services.

Claims submitted for services provided on and after May 1, 2019 to patients enrolled in Horizon BCBSNJ MA plans will be processed as follows.

  • Based on the submitted diagnosis code(s), CPT codes 11950, 11951, 11952 or 11954 may be denied as cosmetic services.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after May 1, 2019.

CPT® is a registered mark of the American Medical Association.

¹ The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ MA plans may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). We follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs in our processing of claims for services provided to our MA members. For those services where no LCD or NCD exists, claims for MA members will be processed based on our policy guidelines.

Published on: January 30, 2019, 15:29 p.m. ET
Last updated on: February 7, 2019, 10:23 a.m. ET