On June 29, 2014, the Centers for Medicare & Medicaid Services (CMS) implemented the invalidation of National Coverage Determination (NCD) 140.3: Transsexual Surgery. Therefore, reasonable and necessary gender reassignment surgery may be covered for AmeriHealth Medicare Advantage HMO/POS members.

Claims submission in 2015

For calendar year 2015, gender reassignment surgery claims for members enrolled in Medicare Advantage HMO/POS products should be submitted to the appropriate Medicare Administrative Contractor (MAC). The MAC will consider whether gender reassignment surgery is reasonable and necessary for AmeriHealth Medicare Advantage members. Please note the following:

• AmeriHealth will not be required to review or provide coverage authorization/precertification for gender reassignment surgery during calendar year 2015.
• Gender reassignment surgery claims should not be submitted directly to AmeriHealth in 2015 for members enrolled in Medicare Advantage Products.
• Gender reassignment surgery claims will not be processed by AmeriHealth in 2015.

Policy changes in 2016

For calendar year 2016, gender reassignment surgery claims will be processed by AmeriHealth. At that time, AmeriHealth will assume responsibility for providing medical necessity review and precertification. Effective January 1, 2016, a coverage policy will be implemented to define medical necessity criteria for gender reassignment surgery for members enrolled in Medicare Advantage HMO/POS products.

If you have any questions, please contact your Network Coordinator or Hospital/Ancillary Services Coordinator.