CMS NCD 368 Modified: What the Gender Dysphoria and Gender Reassignment Surgery Policy Change Means for Your Practice

The Centers for Medicare & Medicaid Services (CMS) has issued a modification to National Coverage Determination (NCD) 368, governing coverage of gender reassignment surgery for Medicare beneficiaries diagnosed with gender dysphoria. As of March 12, 2026, this policy update reaffirms the existing framework established in August 2016—but the modification itself signals that CMS has conducted a fresh review of the determination, making this the right moment for billing teams to audit their current workflows and MAC-specific coverage guidance.

What CMS NCD 368 Actually Says About Gender Reassignment Surgery Coverage

Under NCD 368, CMS has determined that no national coverage determination is appropriate for gender reassignment surgery for Medicare beneficiaries with gender dysphoria. That language is precise and consequential: CMS is not designating these procedures as covered, and it is not designating them as non-covered at the national level. The policy explicitly notes both the "Nationally Covered Indications" and "Nationally Non-Covered Indications" sections are listed as N/A.

What fills that vacuum is local decision-making. Coverage determinations fall to the individual Medicare Administrative Contractors (MACs) under Section 1862(a)(1)(A) of the Social Security Act. Each MAC evaluates claims on a case-by-case basis, applying its own local coverage determinations and medical necessity standards.

This decentralized structure has significant operational implications. A claim that gets paid in one MAC jurisdiction may be denied in another—and your billing team needs to know exactly which MAC covers your geographic region and what that MAC's current LCD says.

The 2016 Baseline — and Why the 2026 Modification Still Matters

The underlying policy dates to August 30, 2016, when CMS formally concluded its National Coverage Analysis on gender reassignment surgery. At that time, after examining the available medical evidence, CMS determined a national determination was not warranted. The policy was last reviewed in August 2016, which is the date noted in the policy document itself.

The March 2026 modification means CMS has formally updated this NCD in some capacity. Billing managers should not treat this as a rubber stamp of the status quo without verification. Policy modifications—even those that preserve existing coverage frameworks—can reflect updated clinical language, changes to the administrative process, or shifts in how medical necessity is evaluated at the local level.

If your practice bills for gender-affirming surgical procedures for Medicare patients, this is not a situation where you wait for a denial to find out what changed. Pull the updated policy documentation, contact your MAC, and compare current LCD guidance against what was in place prior to March 12, 2026.

How Medicare Coverage Is Actually Determined Under This NCD

Because NCD 368 defers to MACs, the practical coverage question for any given claim depends on the following:

Medical necessity under Section 1862(a)(1)(A) of the Social Security Act. Services must be reasonable and necessary for the diagnosis or treatment of illness or injury. For gender reassignment surgery, MACs apply this standard in the context of a gender dysphoria diagnosis. Documentation of the diagnosis, clinical history, and treatment pathway is essential.

MAC-specific LCD guidance. Each MAC may have published an LCD that outlines what documentation it requires, whether prior authorization or prior determination requests are accepted, and how it defines medical necessity for specific procedures in this category.

Case-by-case adjudication. Even where a MAC has published an LCD, individual claims are still subject to case-by-case review. This means clinical documentation—letters from treating mental health providers, history of gender-affirming care, surgical records—needs to be thorough and organized before a claim is submitted.

There are no nationally mandated prior authorization requirements under this NCD, but your MAC may impose its own. Check directly.

Affected Codes

The policy document for NCD 368 does not list specific CPT, HCPCS, or ICD-10 codes. No codes appear in the current policy data.

This is itself a meaningful data point. The absence of enumerated codes reinforces the case-by-case, MAC-dependent nature of coverage under this NCD. Billing teams should not assume a specific CPT code is covered or excluded based on this NCD alone.

To identify the codes your MAC is adjudicating—and under what criteria—you need to review your MAC's current LCD directly. Common MAC jurisdictions include Novitas Solutions, CGS Administrators, WPS Government Health Administrators, First Coast Service Options, and Palmetto GBA, among others. CMS maintains a list of MACs by state at cms.gov.

What Your Billing Team Should Do