In September 2022, WPATH released the Standards of Care (SOC) version 8, for trans and gender-diverse medical and mental healthcare. Included in Appendix D are the new letter referral suggestions for gender-affirming surgery (GAS).
Though WPATH has released the new SOC, it will take insurance companies time to evolve. Until then, CCTS will continue to require all patients using insurance for GAS to follow the SOC v7 guidelines. This adherence to the outdated guidelines will prevent any last-minute and unfortunate denials based on insufficient letter submission.
Please be aware some insurance companies/plan have additional requirements, outside the published SOC. We recommend verifying letter requirements with your specific insurance plan.
- All health plans require letters for revisions if original letters are greater than 1 year old
- Blue Cross Blue Shield (all subsidiaries): prefer letters to be from Doctorate level providers
- Anthem BCBS: 2 MH letters for Top and bottom surgery dated within 6 months
*Please note that WPATH Standards of Care state that the patient should be the age of majority (18 years of age in the US) for surgery coverage. It is very uncommon for a minor to have this procedure approved.*
If you are pursuing surgery as a self-pay patient and have submitted a signed agreement along with your deposit, we will gladly honor the new SOC v8, 1 mental health letter from a licensed mental health provider.
WPATH SOC 7 Letter Requirements
Important: Letters missing any of the required elements below will be returned for correction. The Crane Center currently follows WPATH SOC 7 requirements as enforced by insurance payers.
Provider & Letter Format
- Letter must be on official letterhead, dated, and signed with a wet signature or verified electronic signature.
- Provider must be a Qualified Mental Health Professional (QMHP).
Accepted credentials include:
LCSW, CSW, MFT, LMFT, LPC, LPC-S, LCPC, LMHC, PMHNP, Ph.D., Psy.D., MD, etc.
Not accepted: associates, candidates, interns, residents, LSW, or PA.
Patient Identification
- Patient’s legal name (as listed on insurance), preferred name (if different), and date of birth.
- Patient’s date of birth must be listed.
Procedure Details
- Letter must clearly state the specific procedure(s) requested (e.g., phalloplasty, vaginoplasty, metoidioplasty, top surgery, chest masculinization, breast augmentation, orchiectomy).
Bundled sub-procedures do not need to be listed.
Provider Relationship
- Date the provider-patient relationship began.
- Confirmation that the patient has been seen at least once within the past 12 months (telehealth or in person).
If only one visit has occurred, the date must be listed, or the patient must be identified as a “new patient.”
Gender Dysphoria Diagnosis Statement
The letter must confirm persistent, well-documented gender dysphoria and include all of the following:
- Desire to live and be accepted as the affirmed gender
- Identity present for at least two years
- Not a symptom of another mental health disorder
- Causes clinically significant distress or impairment
All four qualifiers must be present.
Transition History
- Confirmation of at least 12 continuous months living in a gender role congruent with gender identity.
- Confirmation of at least 12 continuous months of hormone therapy
(Required for bottom surgery and breast augmentation only.)
Capacity & Compliance
- Statement confirming capacity for informed consent.
- Statement confirming ability to comply with long-term follow-up and post-operative expectations.
Medical & Behavioral Stability
- Statement that any significant medical or mental health conditions are reasonably well controlled.
- If substance use is mentioned, confirmation it can be well controlled for at least six months prior to surgery.
Provider Experience
- Statement describing the provider’s experience treating patients with gender dysphoria.
Instructions:
To submit your letter for review, please upload it directly to your Athena Patient Portal using the link below:
https://30614-1.portal.athenahealth.com/
How to Upload Your Letter in Athena:
- Log in to your portal
- Click “Messages”
- Select “Send a Message”
- Choose “Statement, Billing , or Insurance Question” (this routes your letter to the correct team)
- Upload your letter as a PDF attachment
- Submit your message