[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-278915-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-278915-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","ur-65-gender-affirming-procedures-medical-necessity-criteria","UR 65 Gender-Affirming Procedures Medical Necessity Criteria","","UR 65 defines medical necessity criteria and coverage guidance for gender-affirming procedures within the KPNW region. It outlines eligibility requirements tied to referrals from a Gender Pathways Clinic physician, minimum age or guardian consent, persistent well-documented gender incongruence, informed consent capacity, and documented mental health assessment(s) and/or a WPATH letter within specified timeframes. The policy also addresses member-specific coverage applicability across Medicare, Medicaid, commercial, self-funded, and FEHB/PSHB programs, including key exclusions and effective date changes.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/general/","General",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/ur-65-gender-affirming-procedures-medical-necessity-criteria/278915/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/ur-65-gender-affirming-procedures-medical-necessity-criteria/278915.png","ImageObject",442,249,{"name":42,"@type":43},"8796093062539","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-20","2026-09-15",true,{"@type":52,"interactionType":53,"userInteractionCount":26},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What is the purpose of the UR 65 gender-affirming procedures criteria?","Question",{"text":62,"@type":63},"UR 65 sets requirements for when gender-affirming procedures meet medical necessity, aiming to align appearance with the patient’s expressed gender identity and alleviate gender dysphoria or gender incongruence.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"Who must generate the referral to be eligible for coverage under UR 65?",{"text":67,"@type":63},"The referral must be generated by a Gender Pathways Clinic (GPC) physician, with a noted exception for members with Added Choice coverage.",{"name":69,"@type":60,"acceptedAnswer":70},"What documentation is required before a surgical consultation under UR 65?",{"text":71,"@type":63},"Eligibility requires documented mental health assessment(s) and/or a WPATH letter from an experienced gender therapist, dated within 12 months prior to the surgical consultation referral.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},278915,1789513807,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,113,118,123],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":110,"show_sort_weight":111,"slug":112},17,"Forms",40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":4,"slug":125},158,"general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":11,"doc_module":22,"category_id":124,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":129,"file_id":130,"file_url":131,"file_type":132,"file_size":133,"view_count":121,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":134,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":79,"read_time":26},8796093062539,"UR 65 Gender-Affirming Procedures Medical Necessity Criteria  \n\n| Department: Non-Behavioral Health\u003Cbr>Section: KPNW Region\u003Cbr>Applies to: KPNW Region\u003Cbr>Subject Matter Expert: Gene deHaan, MD, Gender Pathways Clinic; Pattie Sandholm, MD, Plastic Surgery; Joanna Jacobs, MD, Head and Neck Surgery | Number: UR 65\u003Cbr>Effective: 12/2023\u003Cbr>Last Reviewed/Revised: 6/24, 11/24, 2/25, 6/25, 10/25, 11/25, 12/25, 4/21/26 |\n| --- | --- |\n\nBACKGROUND  \nGoals of surgery: to bring appearance into the cisgendered range for the patient’s expressed gender identity, with the goal of alleviating gender dysphoria/gender incongruence.  \nInternal & Outside Referral Guidelines:  \nKaiser Foundation Health Plan (KFHP) provides Gender-Affirming Procedures for the treatment of gender dysphoria/ gender incongruence when the below medical criteria are met.  \nMembers whose employer groups do not cover Gender-Affirming Procedures but who wish to access these services out of pocket, will be evaluated according to the same medical criteria.  \nPOLICY AND CRITERIA  \nCoverage guidance: Gender-affirming procedures may be excluded from coverage. Check CM for exclusions or limitations.  \n\n| Source | Policy |\n| --- | --- |\n| For Medicare Members |  |\n| CMS Coverage Manuals | None |\n| National Coverage Determinations (NCD) | NCD 140.9 “Gender Dysphoria and Gender Reassignment Surgery” |\n| Local Coverage Determinations (LCD) | None |\n| Local Coverage Article | None |\n| Kaiser Permanente Medical Policy for Medicare Members | UR 65 applies. The available NCD indicates that CMS determined that no NCD is appropriate at this time for“gender reassignment surgery for Medicare beneficiaries with gender dysphoria” and that “in the absence of an NCD, coverage determinations for gender reassignment surgery…will continue to be made by the local Medicare Administrative Contractors (MACs) on a case-by-case basis.” |\n| For Medicaid Members |  |\n| OR Medicaid | UR 65 does not apply. See OHP Prioritized List, Guideline Note 127 for treatment of Gender Dysphoria |\n| WA Medicaid | UR 65 does not apply. Surgical procedures related to gender affirmation/reassignment are covered on a fee-for-service basis (HCA Physician-Related Services/ Healthcare |\n\n\n|  | Professional Services Medicaid Provider Guide, Transgender Health Services; and WAC 182-531-1675 |\n| --- | --- |\n| Commercial and Self-Funded Members |  |\n| OR Commercial | UR 65 applies |\n| WA Commercial | UR 65 applies |\n| Self-Funded Plans | Self-Funded groups must be verified to see if they have a benefit for gender-affirming procedures (GRS in CM) . If so, UR 65 applies. |\n| FEHB and PSHB Programs | Through 12/31/25, UR 65 applies. Effective 1/1/2026 UR 65 does not apply.\u003Cbr>For Plan Year 2026, chemical and surgical modification of an individual’s sex traits through medical interventions (to include “gender transition” services) will no longer be covered under the FEHB or PSHB Programs.\u003Cbr>This exclusion expands upon Carrier Letter 2025-01a and applies regardless of age. As an exception, counseling services for possible or diagnosed gender dysphoria must still be covered. Covered counseling services must be provided by a licensed mental health provider and may include those who provide faith-based counseling.\u003Cbr>FEHB and PSHB Program members can apply for an exception to the rule (ETR) review if they are in the middle of current treatment. |\n\nMembers are eligible for coverage of gender-affirming procedures if they meet all of the following criteria and any related procedure-specific criteria (if they exist – see below):  \n1. Referral must be generated by a Gender Pathways Clinic (GPC) physician*; AND  \n*NOTE: This criterion is not applicable to referrals for members with Added Choice coverage.  \n2. Age 18 years or older OR age less than 18 years with parent/guardian consent or are legally emancipated, AND  \n3. Persistent, well-documented gender incongruence; AND  \n4. Capacity to make a fully informed decision and to consent for tre","cbCaiko326oSUd0u","https://ap.wps.com/l/cbCaiko326oSUd0u","pdf",205076,6,"English","# Background\n## Goals of surgery\n## Referral guidelines\n# Policy and criteria\n## Coverage guidance\n## Medicare members\n## Medicaid members\n## Commercial and self-funded members\n## FEHB and PSHB programs\n# Eligibility criteria for coverage\n## Referral and age requirements\n## Documentation and informed consent\n## Mental health and medical readiness\n## Nicotine-free and primary care paneling","[{\"question\":\"What is the purpose of the UR 65 gender-affirming procedures criteria?\",\"answer\":\"UR 65 sets requirements for when gender-affirming procedures meet medical necessity, aiming to align appearance with the patient’s expressed gender identity and alleviate gender dysphoria or gender incongruence.\"},{\"question\":\"Who must generate the referral to be eligible for coverage under UR 65?\",\"answer\":\"The referral must be generated by a Gender Pathways Clinic (GPC) physician, with a noted exception for members with Added Choice coverage.\"},{\"question\":\"What documentation is required before a surgical consultation under UR 65?\",\"answer\":\"Eligibility requires documented mental health assessment(s) and/or a WPATH letter from an experienced gender therapist, dated within 12 months prior to the surgical consultation referral.\"}]","UR 65 Gender-Affirming Procedures Medical Necessity Criteria | PDF"]