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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
The rules state that surgical treatment for gender dysphoria may be considered medically necessary when ALL 
of the following criteria are met: 
1. The individual is at least 18 years of age. 
2. A gender reassignment treatment plan is created specific to an individual beneficiary 
3. The individual has a documented Diagnostic and Statistical Manual of Mental Disorders -Fifth Edition, 
DSM-5 TM diagnosis of GD: 
 A. A marked incongruence between ones experienced/expressed gender and assigned gender, of at least 6 
months duration, as manifested by at least two of the following:  
1. A marked incongruence between ones experienced/expressed gender and primary and/or secondary sex 
characteristics.  
2. A strong desire to be rid of ones primary and/or secondary sex characteristics because of a marked 
incongruence with ones experienced/expressed gender.  
3. A strong desire for the primary and/or secondary sex characteristics of the other gender.  
4. A strong desire to be of the other gender (or some alternative gender different from ones assigned 
gender).  
5. A strong desire to be treated as the other gender (or some alternative gender different from ones 
assigned gender). 
6. A strong conviction that one has the typical feelings and reactions of the other gender (or some 
alternative gender different from ones assigned gender). 
 B. The condition is associated with clinically significant distress or impairment in social, occupational or other 
important areas of functioning. 
1. One letter from a mental health professional that the patient has had, at minimum, twelve months of 
psychotherapy therapy sessions attesting to all of the following clinical criteria:  
A. That any co-morbid psychiatric or other medical conditions are stable and that the individual is 
prepared to undergo surgery. 
B. That the patient has had persistent and chronic gender dysphoria. C. That the patient has completed twelve months of continuous, full-time, real-life experience (i.e., 
the act of fully adopting a new or evolving gender role or gender presentation in everyday life) 
in the desired gender. 
2. The individual, if required by the mental health professional provider, has regularly participated in 
psychotherapy throughout the real-life experience at a frequency determined jointly by the individual 
and the mental health professional provider. 
3. Unless medically contraindicated (or the individual is otherwise unable to take cross-sex hormones), 
there is documentation that the individual has participated in twelve consecutive months of cross-sex 
hormone therapy of the desired gender continuously and responsibly (e.g., screenings and follow-ups 
with the professional provider). 
4. The individual has knowledge of all practical aspects (e.g., required lengths of hospitalizations, likely 
complications, and post-surgical rehabilitation) of the gender reassignment surgery. 
You can find this rule in the Local Coverage Article Billing and Coding for Gender Reassignment Services for 
Gender Dysphoria, A53793. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.