Provider Notices


Gender Affirming Surgery - Preapproval Requirements - Effective December 3, 2018

11/2/2018 4:26:24 PM

Beginning December 3, 2018 a preapproval will be required with the following diagnosis codes: 

  • F64.1 – Gender dysphoria in adolescence and adulthood
  • F64.2 – Gender dysphoria of childhood
  • F64.8 – Other dysphoria disorders
  • F64.9 – Gender dysphoria, unspecified
  • Z87.890 – Personal history of sex reassignment

 

Additionally, the following codes require a preapproval/PA if associated with the above diagnosis codes:

11980

17380

17999

19303

19304

19325

19350

21120

21121

21123

21125

21127

21208

21209

30400-30420

30430-30450

31899

53430

54125

54400-55417

54520

54660

54690

55175

55180

55899

55970

55980

56625

56805

56810

58150

57106-57107

57110-57111

57291-57292

57335

58180

58260-58262

58275-58291

58541-58544

58550-58554

58570-58573

58661

58720

67900

11954

15836

21137

21138

21139

11954

Please call PacificSource with any questions regarding this change.


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