Gender Dysphoria Treatment - (0266) — MM 0266 | CIGNA Coverage Update

Cigna modified MM 0266 for gender dysphoria treatment, effective January 16, 2026. Here's what changes for billing teams.

Cigna Healthcare updated its gender dysphoria treatment coverage policy under MM 0266, affecting over 119 CPT codes tied to gender-affirming surgical procedures. The update draws a sharper line between procedures Cigna considers medically necessary and those it deems not medically necessary — a distinction your billing team needs to understand before submitting claims. If you bill for gender-affirming surgery, chest reconstruction, genital reconstruction, or facial procedures under this policy, audit your charge capture now.

Quick-Reference Table

Cigna Gender Dysphoria Coverage Criteria and Medical Necessity Requirements 2026

The MM 0266 Cigna coverage policy splits covered procedures into two clear buckets. Procedures that meet the applicable criteria are considered medically necessary. Procedures that don't meet those criteria — including many facial and body contouring procedures — are generally considered not medically necessary.

The policy defines gender dysphoria as marked incongruence between one's experienced or expressed gender and primary and/or secondary sex characteristics. The American Psychiatric Association's definition — "psychological distress that results from an incongruence between one's sex assigned at birth and one's gender identity" — is the clinical standard Cigna references. Your documentation needs to reflect this clinical basis.

Cigna uses the terms gender reassignment, gender confirming, and gender-affirming interchangeably under this policy. For billing purposes, that means procedures coded under any of these labels fall under MM 0266 and must meet the same medical necessity threshold.

The covered procedures span a wide range. Genital reconstruction codes like CPT 55970 (intersex surgery, male to female) and CPT 55980 (female to male) are covered when criteria are met. So are hysterectomy codes — CPT 58150, 58260, 58262, 58291 — and laparoscopic variants like CPT 58552, 58554, 58571, and 58573. Orchiectomy via CPT 54520 and laparoscopic orchiectomy CPT 54690 are covered. Breast augmentation (CPT 19325) and tissue expander procedures (CPT 19357, 11960, 11970, 11971) are covered when criteria are met.

Prior authorization requirements for these procedures are standard under Cigna's surgical coverage policies. Confirm prior auth requirements for each specific procedure before scheduling. A failed prior authorization is the fastest path to a claim denial on high-cost surgical codes.

Reimbursement for these procedures depends entirely on meeting Cigna's criteria. Generic documentation won't hold up. Your clinical notes need to establish the diagnosis, document the incongruence, and tie the procedure directly to the treatment plan.

Cigna Gender Dysphoria Exclusions and Non-Covered Indications

This is where billing teams get hurt. Cigna's MM 0266 coverage policy flags a significant list of procedures as "generally not medically necessary" when performed as part of gender dysphoria treatment. These are mostly facial and body contouring procedures.

Rhytidectomy codes — CPT 15824 through 15829 — are not covered. That covers forehead lifts, neck tightening, glabellar frown line correction, cheek and chin work, and SMAS flap procedures. Blepharoplasty (CPT 15820, 15821, 15822, 15823) is not covered. Dermabrasion across all variants (CPT 15780, 15781, 15782, 15783, 15786, 15787) is not covered. Chemical peels — CPT 15788, 15789, 15792, 15793 — are not covered.

Body contouring procedures including pannus excision (CPT 15830) and thigh excision (CPT 15832) fall into the not-medically-necessary bucket as well. Hair transplant procedures CPT 15775 and 15776 are excluded. Subcutaneous filler injections (CPT 11950, 11951, 11952, 11954) are not covered.

The real issue here is billing these codes in combination with covered surgical procedures. If you bundle a covered genital reconstruction with a facial feminization procedure that Cigna considers not medically necessary, expect the secondary codes to be denied. Split the claims and make sure your team understands the distinction before submitting.

Coverage Indications at a Glance

Cigna Gender Dysphoria Billing Guidelines and Action Items 2026

CPT, HCPCS, and ICD-10 Codes for Gender Dysphoria Treatment Under MM 0266

Covered CPT Codes (When Medical Necessity Criteria Are Met)

Not Covered CPT Codes (Generally Not Medically Necessary)

Note: The full policy data includes 39 additional CPT codes in the not-covered group not listed in the source data excerpt above. Access the complete MM 0266 policy document at app.payerpolicy.org for the full code list.