Skip to main content

HCPCS/CPT C1813, Prosthesis, penile, inflatable | No Prior Auth

Backwork Sign up free

Ask Backwork/C1813

`C1813`, Prosthesis, penile, inflatable

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

The listed documentation items must be submitted for review to determine whether policy criteria are met; missing items may impact the review outcome.
Submit History and Physical and/or chart notes.
Provide documentation of the therapy requested, if applicable.
Provide documentation of the patient's capacity to make decisions and consent to treatment.

Key Coverage Criteria

Procedures that normally do not require a prescription (for example hair removal or nipple tattooing) may be considered prescribed if there is a referral for the procedure from a licensed mental health professional.

1 Active Policy

REGENCE-MED153, Gender Affirming Interventions for Gender Dysphoria

Related Codes

11921(1 policies)11950(1 policies)11951(1 policies)11952(1 policies)11954(1 policies)11970(1 policies)11971(1 policies)11920(1 policies)

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about C1813 Sign up free

For medical treatment or mastectomy: submit documentation that a licensed mental health professional has diagnosed gender dysphoria; documentation of how long the patient has been living as their desired gender; documentation of duration of therapy including therapist licensure; and for patients under 18, a documented provider determination of medical necessity for earlier intervention.

For all surgical treatments: provide documentation that at least one licensed mental health professional has diagnosed gender dysphoria, and documentation that a licensed health care or mental health professional experienced in assessing/treating gender dysphoria has recommended the surgical treatment; experience may be demonstrated by WPATH certification or a statement of experience (e.g., letter or chart note).