Appendix J: WPATH Letter Template for Vaginoplasty#

Requesting-Program Documentation Overview#

Use only if your surgeon, payer, or program requires written documentation; obtain its exact current criteria first. This adaptable template does not state that SOC8 itself requires a letter, a particular issuer, a diagnosis, therapy, social-role history, or a hormone duration. Record the requesting organization, procedure, jurisdiction, policy/version, criteria date, issuer requirements, and what each requested item must address. Include only information the requester actually requires and the clinician can support.

Template Letter#

[Provider Letterhead]

[Date]

Re: Letter of Support for Gender-Affirming Surgery (Vaginoplasty) Patient: [Patient Legal Name] Date of Birth: [DOB] Requested Procedure: Vaginoplasty

To Whom It May Concern:

I am writing at the request of [surgeon / payer / program] to address its written-documentation criteria for [procedure], if written documentation is required. The requester’s current criteria are [policy / form / version / date], and this letter addresses only the items listed there.

Provider Qualifications#

I am a [licensed clinical psychologist / licensed clinical social worker / licensed professional counselor / psychiatrist] in the state of [State], license number [License Number]. I have [X years] of experience providing mental health services, including [X years] specializing in gender-diverse populations. I have completed training in gender-affirming care, including [list relevant training, certifications, or continuing education—e.g., WPATH GEI certification, specific gender health trainings].

Clinical Relationship#

I have been providing [psychotherapy / mental health services / psychiatric care] to [Patient Name] since [Start Date]. During this time, I have conducted [number] sessions with the patient, including comprehensive assessment of their gender identity, mental health history, and readiness for surgical intervention. [If this is an assessment-only relationship rather than ongoing therapy, adjust accordingly: "I conducted a comprehensive gender assessment with [Patient Name] on [Date(s)], consisting of [number] clinical interviews totaling [X] hours."]

Requester-Specified Diagnosis / Classification (only if required)#

[If the requester requires a diagnosis or classification: state [exact requester-required diagnosis/classification], [coding system/version if required], [assessment basis], and [date]. Do not select DSM or ICD wording unless the requester requires it and the clinician can support it.]

Requesting Program / Payer Criteria Assessment#

Use the fields below only for the current requester’s quoted criteria. For each item, identify [requester / payer / program], [policy or form version], [effective or retrieved date], [exact criterion], and the clinician-supported response. Do not represent a generic template item as a universal SOC8, payer, or program rule.

[Requester criterion 1: quote the exact current requirement. The former generic prompt “Persistent, well-documented gender incongruence” is only an example and must not be treated as a universal requirement.] [Patient Name] has experienced gender incongruence since [approximate age/timeframe]. [Brief description of history—e.g., "They first recognized their gender identity differed from their sex assigned at birth in early adolescence and have consistently identified as [gender] for [X] years."] Their gender identity as [woman/their identified gender] has remained stable throughout our clinical relationship.

[Requester criterion 2: quote the exact current requirement. The former generic prompt “Capacity to make a fully informed decision and consent to treatment” is only an example and must not be treated as a universal requirement.] I have assessed [Patient Name]'s capacity to provide informed consent. [He/She/They] demonstrates clear understanding of:

The nature of the proposed surgical procedure
The expected outcomes, benefits, and limitations
The potential risks and complications
The alternatives to surgery
The permanence and irreversibility of the procedure
The post-operative requirements, including lifelong dilation

[Patient Name] has engaged thoughtfully with these considerations and has made an informed, autonomous decision to pursue vaginoplasty.

[Requester criterion 3: quote the exact current requirement. The former generic prompt “Age of majority” is only an example and must not be treated as a universal requirement.] [Patient Name] is [age] years old, above the age of majority.

[Requester criterion 4: quote the exact current requirement. The former generic prompt “Mental health concerns are reasonably well controlled” is only an example and must not be treated as a universal requirement.] [Choose the appropriate option:]

[If no significant mental health concerns:] [Patient Name] does not have any mental health conditions that would impair their ability to consent to or recover from surgery.

[If mental health conditions are present but well-managed:] [Patient Name] has a history of [condition(s)—e.g., depression, anxiety, PTSD]. These conditions are currently [well-controlled / in stable remission / effectively managed] through [treatment—e.g., ongoing therapy, medication, self-management strategies]. [His/Her/Their] mental health conditions do not impair their decision-making capacity regarding surgery, and [he/she/they] has demonstrated the stability and coping resources necessary for surgical recovery. [If applicable: "It is worth noting that [his/her/their] gender dysphoria has been a significant contributor to [his/her/their] mental health challenges, and only if supported by the completed current-authority fields above, the clinician offers this limited case-specific opinion about [his/her/their] overall psychological wellbeing."]

[Requester criterion: hormone history, duration, anatomy, or treatment information—quote the exact current requirement if it applies.] [Choose the appropriate option:]

[If on hormone therapy:] [Include only if the requester asks for this information:] [Patient Name] has been receiving [hormone treatment / no hormone treatment] under [prescriber] since [date]. State only the history, indication, contraindication, or treatment goal relevant to the requester’s written criterion; do not turn a duration into a universal SOC8 rule.

[If hormone therapy is contraindicated or not desired:] [Patient Name] [has a medical contraindication to / has chosen not to pursue] hormone therapy. [Brief explanation.] [Current hormone-related criterion or authority for the requested vaginoplasty procedure — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Recommendation#

[If the requester requires a clinical opinion: state [clinician’s independently supported opinion], [exact requested procedure/components], [requester’s quoted criterion], [policy/form version and date], and the supporting record. This is not an approval decision or a universal conclusion.]

[Patient Name] has [clinician-supported, case-specific decision-making and support information] responsive to [exact current requester criterion]. [Current authority for any clinical opinion or outcome-related statement — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Contact Information#

Please do not hesitate to contact me if you require additional information.

Sincerely,

[Signature]

[Provider Name], [Credentials] [Title] [Practice Name] [Address] [Phone] [Email] [License Number and State] [NPI Number, if applicable]

Checklist for Providers#

Ensure your letter includes:

Your full credentials and license number
Your qualifications to write this letter (training, experience with gender-diverse patients)
Duration and nature of clinical relationship
DSM-5 or ICD-11 diagnosis
Assessment of each exact current requester / payer / program criterion, with policy/form version and date
Confirmation of informed consent capacity
Discussion of any mental health conditions and their management
Hormone therapy status (if applicable)
Clear statement of support/recommendation
Your contact information
Date and signature

Notes for Patients#

Share this template with your provider before your appointment.
Confirm current requirements. [Current vaginoplasty documentation and coverage record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.] Do not infer a number of letters or issuer type from this template.

Request the letter on letterhead with original signature if possible.
Keep multiple copies—original for surgeon, copies for insurance, your records.
Review the letter before your provider sends it to ensure all criteria are addressed.
Timeline: Request the letter 4-8 weeks before you need it. Providers may need time to write comprehensive letters.

Appendix K: WPATH Letter Template for Nulloplasty#

Special Considerations for Nulloplasty#

[Current nulloplasty procedure and documentation record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Use this letter to explain the exact proposed operation, the requester’s stated documentation question, and the clinician-supported patient-specific rationale. Do not describe prevalence, professional recognition, or procedural status as universal.

Template Letter#

[Provider Letterhead]

[Date]

Re: Letter of Support for Gender-Affirming Surgery (Nulloplasty/Genital Nullification) Patient: [Patient Legal Name] Date of Birth: [DOB] Requested Procedure: Nulloplasty (Genital Nullification Surgery)

To Whom It May Concern:

I am writing at the request of [surgeon / payer / program] to address its written-documentation criteria for [nulloplasty or exact proposed operation], if written documentation is required. The requester’s current criteria are [policy / form / version / date], and this letter addresses only the items listed there.

Provider Qualifications#

I am a [licensed clinical psychologist / licensed clinical social worker / licensed professional counselor / psychiatrist] in the state of [State], license number [License Number]. I have [X years] of experience providing mental health services, including [X years] specializing in gender-diverse populations. I have completed training in gender-affirming care, including [list relevant training, certifications, or continuing education]. I have specific experience working with nonbinary, genderqueer, and gender-diverse individuals whose gender identities and surgical goals may differ from binary transgender presentations.

Clinical Relationship#

Understanding Nulloplasty#

[Exact nulloplasty operation and case-specific rationale — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

The surgical team describes [exact operation, retained/removed structures, alternatives, and limitations] for this patient. The clinician may state only the patient-specific rationale supported in the record, including:

Nonbinary individuals
Agender individuals
Those who identify as neutrois or gender-neutral
Individuals whose embodiment goals include genital smoothness
Transgender individuals who do not desire reconstruction of binary genitalia

[Current authority for nulloplasty description or eligibility — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Requester-Specified Diagnosis / Classification (only if required)#

[Patient Name]'s gender dysphoria specifically involves distress related to having external genitalia. [He/She/They] has consistently expressed that [his/her/their] authentic embodiment does not include having a penis, vagina, or other external genital structures. This is a stable, persistent aspect of [his/her/their] gender identity, not a transient preference or the symptom of another condition.

Requesting Program / Payer Criteria Assessment#

[Requester criterion 1: quote the exact current requirement. The former generic prompt “Persistent, well-documented gender incongruence” is only an example and must not be treated as a universal requirement.] [Patient Name] has experienced gender incongruence since [approximate age/timeframe]. [He/She/They] identifies as [patient's stated gender identity—e.g., nonbinary, agender, genderqueer, etc.] and has consistently expressed that [his/her/their] ideal body would not include external genitalia. This desire for genital nullification has been stable for [duration] and reflects [his/her/their] authentic sense of embodiment.

[Patient Name] has thoughtfully explored their gender identity and surgical options. [He/She/They] is not pursuing nulloplasty due to confusion, avoidance of other surgical options, or external pressure, but rather because this specific surgical outcome aligns with [his/her/their] genuine gender identity and embodiment goals.

The nature of nulloplasty and what the surgical outcome will look like
The permanence and irreversibility of the procedure
That this surgery removes the option for future construction of a vagina or phallus (or significantly complicates such procedures)
The potential risks and complications
The alternatives, including other surgical options and choosing not to pursue surgery
Post-operative care requirements

[Patient Name] has engaged thoughtfully with these considerations over [timeframe]. [He/She/They] has not made this decision impulsively but has arrived at it through careful self-reflection and exploration of options.

[If no significant mental health concerns:] [Patient Name] does not have any mental health conditions that would impair their ability to consent to or recover from surgery.

[If applicable:] [Patient Name]'s gender dysphoria has been a significant contributor to [his/her/their] psychological distress, and, only if supported by the completed current-authority fields above, I offer the following limited case-specific clinical opinion: [his/her/their] mental health and quality of life.

[Requester criterion: hormone history, duration, anatomy, or treatment information—quote the exact current requirement if it applies.] [Choose the appropriate option:]

[If on hormone therapy:] [Patient Name] has been receiving [feminizing/masculinizing] hormone therapy under the supervision of [prescriber name/practice] since [date].

[If not on hormone therapy:] [Patient Name] [has chosen not to pursue / has a medical contraindication to / does not require] hormone therapy as part of [his/her/their] gender-affirming care. [Current hormone-related criterion or authority for the requested procedure — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.] [Patient Name]'s decision [not to pursue hormones / to delay hormones / regarding hormones] is consistent with [his/her/their] gender identity and treatment goals, and does not indicate ambivalence about surgery.

[If applicable:] [Current authority and case record for a hormone-related statement — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Addressing Potential Concerns About Nonbinary Surgical Goals#

I want to address any potential concerns that might arise regarding nulloplasty as a "non-standard" surgical option:

This is not an impulsive decision. [Patient Name] has explored their gender identity and surgical options extensively over [timeframe]. Their desire for genital nullification is persistent, consistent, and well-considered.
Current authority and patient-specific rationale. [Current authority for any statement about identity or surgical options — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Case-specific decision record. [Current evidence or clinical record for outcome-related language — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.] Do not state population regret rates or predict this patient’s surgical outcome.

This is not avoidance. [Patient Name] is not choosing nulloplasty because they are "unsure" whether they want a vagina or phallus. Rather, they are certain that neither of those outcomes aligns with their embodiment goals.

Recommendation#

[Patient Name]'s stated surgical goals are documented in the current case record. [Current clinician-supported, case-specific decision-making, support, and follow-up information responsive to the exact requester criterion; do not predict surgical navigation or recovery.]

[If the requester asks for a recommendation: provide [clinician’s independently supported recommendation] for [exact procedure/components] and [exact requester criterion]. Do not present this template as an approval determination.]

Contact Information#

Please do not hesitate to contact me if you require additional information or wish to discuss this case.

Sincerely,

[Signature]

[Provider Name], [Credentials] [Title] [Practice Name] [Address] [Phone] [Email] [License Number and State] [NPI Number, if applicable]

Checklist for Providers#

Ensure your letter includes:

Your full credentials and license number
Your qualifications, including experience with nonbinary/gender-diverse patients
Duration and nature of clinical relationship
DSM-5 or ICD-11 diagnosis
Explanation of what nulloplasty is (recipient may be unfamiliar)
Affirmation that nonbinary identities and surgical goals are valid
Assessment of each exact current requester / payer / program criterion, with policy/form version and date
Confirmation of informed consent capacity, including understanding of permanence
Discussion of any mental health conditions and their management
Clear statement of support/recommendation
Proactive addressing of potential concerns
Your contact information
Date and signature

Notes for Patients#

Confirm the current local record. [Current surgeon, payer, coding, and appeal information for nulloplasty — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Ask the surgical office and payer for the exact procedure description, billing path, documentation criteria, and appeal process that apply to this request. Do not infer them from this template or a different procedure.
A clinician may use a current authority only for its stated scope and a patient-specific record only for the fact it documents.

Appendix L: WPATH Letter Template for Phalloplasty#

Requesting-Program Documentation Overview#

Special Considerations for Phalloplasty#

[Current phalloplasty surgical-plan record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Document only the surgical team’s current plan: [stages, donor site, urethral-lengthening decision, implants, recovery plan, alternatives, and known limitations]. The letter addresses the patient’s documented understanding of that plan, not a universal phalloplasty pathway.

Template Letter#

[Provider Letterhead]

[Date]

Re: Letter of Support for Gender-Affirming Surgery (Phalloplasty) Patient: [Patient Legal Name] Date of Birth: [DOB] Requested Procedure: Phalloplasty [and related procedures: urethral lengthening, scrotoplasty, vaginectomy, erectile device implantation—list as applicable]

To Whom It May Concern:

I am writing at the request of [surgeon / payer / program] to address its written-documentation criteria for [phalloplasty and exact components], if written documentation is required. The requester’s current criteria are [policy / form / version / date], and this letter addresses only the items listed there.

Provider Qualifications#

I am a [licensed clinical psychologist / licensed clinical social worker / licensed professional counselor / psychiatrist] in the state of [State], license number [License Number]. I hold a [doctoral degree / master's degree] in [field] from [institution]. I have [X years] of experience providing mental health services, including [X years] specializing in gender-diverse populations. I have completed training in gender-affirming care, including [list relevant training, certifications, or continuing education—e.g., WPATH GEI certification, specific gender health trainings].

Clinical Relationship#

I have been providing [psychotherapy / mental health services / psychiatric care] to [Patient Name] since [Start Date]. During this time, I have conducted [number] sessions with the patient, including comprehensive assessment of their gender identity, mental health history, and readiness for surgical intervention. [If this is an assessment-only relationship: "I conducted a comprehensive gender assessment with [Patient Name] on [Date(s)], consisting of [number] clinical interviews totaling [X] hours."]

Requester-Specified Diagnosis / Classification (only if required)#

Requesting Program / Payer Criteria Assessment#

[Requester criterion 1: quote the exact current requirement. The former generic prompt “Persistent, well-documented gender incongruence” is only an example and must not be treated as a universal requirement.] [Patient Name] has experienced gender incongruence since [approximate age/timeframe]. [He/They] identifies as [man / transmasculine / patient's stated identity] and has consistently expressed this identity for [duration]. [Brief relevant history—e.g., "He socially transitioned in [year] and has lived consistently as male in all areas of his life since that time."]

[His/Their] desire for phalloplasty is consistent with [his/their] gender identity and represents a carefully considered decision to align [his/their] body with [his/their] authentic sense of self.

[Requester criterion 2: quote the exact current requirement. The former generic prompt “Capacity to make a fully informed decision and consent to treatment” is only an example and must not be treated as a universal requirement.] I have thoroughly assessed [Patient Name]'s capacity to provide informed consent for phalloplasty. This is a particularly important consideration given the complexity of this surgical pathway. [He/They] demonstrates clear understanding of:

[Current surgical-team plan and dated authority: exact stages, technique, components, risks, alternatives, expected limitations, and aftercare for the requested procedure]
[Patient-specific documented understanding of that current plan]

[Patient Name] has researched phalloplasty extensively, consulted with [his/their] surgical team, and engaged thoughtfully with these considerations. [He/They] has made an informed, autonomous decision to pursue this surgical pathway.

[If no significant mental health concerns:] [Patient Name] does not have any mental health conditions that would impair [his/their] ability to consent to or recover from surgery. [He/They] demonstrates the psychological resilience and stability necessary for the extended phalloplasty surgical journey.

I have specifically assessed [his/their] capacity to manage the psychological demands of multi-stage surgery, including:

Tolerating extended periods between surgical stages
Coping with potential complications or revisions
Managing expectations during the lengthy process
Maintaining mental health stability throughout recovery

[Patient Name] has demonstrated the coping resources, support systems, and psychological stability necessary for this surgical pathway. [His/Their] gender dysphoria has been a significant contributor to [his/their] psychological distress, and, only if supported by the completed current-authority fields above, I offer the following limited case-specific clinical opinion: [his/their] mental health and quality of life.

[Requester criterion: hormone history, duration, anatomy, or treatment information—quote the exact current requirement if it applies.] [Include only if the requester asks for this information:] [Patient Name] has been receiving [hormone treatment / no hormone treatment] under [prescriber] since [date]. State only the history, indication, contraindication, or treatment goal relevant to the requester’s written criterion; do not turn a duration into a universal SOC8 rule.

[If hormone therapy is not being pursued, explain why and note that [Current hormone-related criterion or authority for the requested procedure — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]]

[Requester criterion 6: quote the exact current requirement. The former generic prompt “Additional considerations for phalloplasty” is only an example and must not be treated as a universal requirement.]

Surgical planning: [Patient Name] has consulted with [surgeon name] and has a clear understanding of the proposed surgical plan, including:

Planned donor site: [forearm / thigh / other]
Urethral lengthening: [Yes, patient desires standing urination / No, patient has elected not to pursue urethral lengthening / To be determined in consultation with surgeon]
Staging plan: [Brief description if known—e.g., "Stage 1 phallus creation and Stage 2 glansplasty and scrotoplasty planned approximately 6 months apart"]
Vaginectomy: [Yes / No / To be performed as part of staging]
Erectile device: [Patient plans to pursue in future stage / Patient has elected not to pursue / To be determined]

Support systems: [Patient Name] has adequate support systems in place for the extended recovery periods, including [describe—e.g., "a supportive partner who will serve as primary caregiver, stable housing, ability to take medical leave from work, and access to follow-up care"].

Realistic expectations: [Patient Name] demonstrates realistic expectations about surgical outcomes. [He/They] understands [the current surgical team’s dated, procedure-specific discussion of expected results, uncertainty, risks, alternatives, and limitations]. Do not predict relief or a particular outcome.

Recommendation#

[Patient Name] has demonstrated the psychological stability, informed decision-making, realistic expectations, and support systems necessary for the phalloplasty surgical pathway. I am confident [he/they] has a case-specific support and follow-up plan documented by [clinician/surgical team]; no outcome is predicted.

Contact Information#

Please do not hesitate to contact me if you require additional information.

Sincerely,

[Signature]

[Provider Name], [Credentials] [Title] [Practice Name] [Address] [Phone] [Email] [License Number and State] [NPI Number, if applicable]

Checklist for Providers#

Ensure your letter includes:

Your full credentials and license number (note if doctoral-level)
Your qualifications to write this letter
Duration and nature of clinical relationship
DSM-5 or ICD-11 diagnosis
Assessment of each exact current requester / payer / program criterion, with policy/form version and date
Specific discussion of informed consent for multi-stage surgery
Patient's understanding of urethral lengthening decision and risks
Patient's understanding of donor site implications
Assessment of support systems for extended recovery
Assessment of realistic expectations
Discussion of any mental health conditions and their management
[Only if requested] hormone history, anatomy, or treatment information required by [surgeon / payer / program / policy version / date]
Clear statement of support/recommendation
Your contact information
Date and signature

Notes for Patients#

Confirm current documentation and authorization requirements. [Current phalloplasty documentation and coverage record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Give the letter writer the current surgical-team plan and the requester’s exact criteria.
Retain the requester’s current written authorization instructions; do not assume a number of letters or stage-specific authorization from this template.
Allow extra time. Given the complexity, providers may need more time to write a thorough phalloplasty letter than for other procedures.

Appendix M: WPATH Letter Template for Metoidioplasty#

Requesting-Program Documentation Overview#

Special Considerations for Metoidioplasty#

[Current metoidioplasty surgical-plan record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Record the exact components, anatomy/hormone information requested, alternatives, surgical-team plan, and patient-specific documented understanding. Do not treat a template description, duration, result, or staging pattern as universal.

Template Letter#

[Provider Letterhead]

[Date]

Re: Letter of Support for Gender-Affirming Surgery (Metoidioplasty) Patient: [Patient Legal Name] Date of Birth: [DOB] Requested Procedure: Metoidioplasty [specify if known: simple metoidioplasty / full metoidioplasty with urethral lengthening / with scrotoplasty / with vaginectomy]

To Whom It May Concern:

I am writing at the request of [surgeon / payer / program] to address its written-documentation criteria for [metoidioplasty and exact components], if written documentation is required. The requester’s current criteria are [policy / form / version / date], and this letter addresses only the items listed there.

Provider Qualifications#

Clinical Relationship#

Requester-Specified Diagnosis / Classification (only if required)#

Requesting Program / Payer Criteria Assessment#

[Requester criterion 1: quote the exact current requirement. The former generic prompt “Persistent, well-documented gender incongruence” is only an example and must not be treated as a universal requirement.] [Patient Name] has experienced gender incongruence since [approximate age/timeframe]. [He/They] identifies as [man / transmasculine / patient's stated identity] and has consistently expressed this identity for [duration]. [His/Their] desire for metoidioplasty reflects a carefully considered decision to align [his/their] body with [his/their] authentic sense of self.

[Current surgical-team discussion for the exact requested components: technique, anatomy-dependent expectations, risks, alternatives, irreversibility, recovery, and limitations]
[Patient-specific documented understanding of that discussion]

[Patient Name] has made an informed decision to pursue metoidioplasty [rather than phalloplasty] because [brief explanation of patient's reasoning—e.g., "he prioritizes maintaining erogenous sensation and prefers a single-stage procedure with a shorter recovery" / "the results align with his embodiment goals" / "he wishes to avoid donor site scarring" / etc.].

[If no significant mental health concerns:] [Patient Name] does not have any mental health conditions that would impair [his/their] ability to consent to or recover from surgery.

[If mental health conditions are present but well-managed:] [Patient Name] has a history of [condition(s)]. These conditions are currently [well-controlled / in stable remission / effectively managed] through [treatment]. [His/Their] mental health conditions do not impair [his/their] decision-making capacity, and [he/they] has demonstrated the stability and coping resources necessary for surgical recovery. [His/Their] gender dysphoria has been a significant contributor to [his/their] psychological distress, and, only if supported by the completed current-authority fields above, I offer the following limited case-specific clinical opinion: [his/their] mental health and quality of life.

[He/They] has [clinician-supported, dated anatomy/treatment history only if requested]. [If relevant: "The surgical team’s current assessment, limits, and exact procedure are documented at [record/date]."]

[Requester criterion 6: quote the exact current requirement. The former generic prompt “Surgical goals and expectations” is only an example and must not be treated as a universal requirement.] [Patient Name] has realistic expectations about metoidioplasty outcomes. [He/They] understands that:

[Current surgical-team, procedure-specific discussion of anatomy-dependent outcomes, function, uncertainty, risks, alternatives, and limitations]

[His/Their] surgical goals are [describe—e.g., "relief from genital dysphoria, ability to urinate standing, and masculine genital appearance consistent with his identity"]. The clinician may describe only [the patient-specific goals and the current surgical-team assessment], without predicting that a goal is achievable.

Recommendation#

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Contact Information#

Please do not hesitate to contact me if you require additional information.

Sincerely,

[Signature]

[Provider Name], [Credentials] [Title] [Practice Name] [Address] [Phone] [Email] [License Number and State] [NPI Number, if applicable]

Checklist for Providers#

Ensure your letter includes:

Your full credentials and license number
Your qualifications to write this letter
Duration and nature of clinical relationship
DSM-5 or ICD-11 diagnosis
Assessment of each exact current requester / payer / program criterion, with policy/form version and date
Patient's understanding of metoidioplasty vs. phalloplasty and reasoning for choice
Patient's understanding of realistic size expectations
If urethral lengthening: understanding of risks and standing urination realities
Discussion of any mental health conditions and their management
[Only if requested] hormone history or anatomy information required by [surgeon / payer / program / policy version / date]
Clear statement of support/recommendation
Your contact information
Date and signature

Notes for Patients#

Confirm your surgical plan. Let your letter writer know whether you're pursuing simple metoidioplasty, full metoidioplasty with urethral lengthening, scrotoplasty, and/or vaginectomy.
Use the exact program requirement. Ask the surgeon or program whether it requests hormone history, an anatomy assessment, or another item, and record its current policy/form version and date rather than assuming a duration.
Be clear about your reasoning. If your provider understands why you've chosen metoidioplasty over phalloplasty (or vice versa), they can write a stronger letter.
Realistic expectations are key. Demonstrating that you understand the realistic outcomes of metoidioplasty strengthens your letter.

Appendix N: WPATH Letter Template for Top Surgery (Chest Masculinization)#

Requesting-Program Documentation Overview#

Requester field: If hormone history is requested, quote the current surgeon, payer, or program criterion and its date. Do not use this template to state a universal hormone-duration rule.

Template Letter#

[Provider Letterhead]

[Date]

Re: Letter of Support for Gender-Affirming Surgery (Chest Masculinization / Top Surgery) Patient: [Patient Legal Name] Date of Birth: [DOB] Requested Procedure: Bilateral mastectomy with chest masculinization (top surgery)

To Whom It May Concern:

I am writing at the request of [surgeon / payer / program] to address its written-documentation criteria for [chest procedure], if written documentation is required. The requester’s current criteria are [policy / form / version / date], and this letter addresses only the items listed there.

Provider Qualifications#

Clinical Relationship#

Requester-Specified Diagnosis / Classification (only if required)#

Requesting Program / Payer Criteria Assessment#

[Requester criterion 1: quote the exact current requirement. The former generic prompt “Persistent, well-documented gender incongruence” is only an example and must not be treated as a universal requirement.] [Patient Name] has experienced gender incongruence since [approximate age/timeframe]. [He/They] identifies as [man / transmasculine / nonbinary / patient's stated identity] and has consistently expressed this identity for [duration].

[He/They] experiences significant distress related to [his/their] chest, which is incongruent with [his/their] gender identity. This chest dysphoria [describe impact—e.g., "significantly impacts his daily functioning, causing him to avoid activities such as swimming and exercise, to wear binding garments that cause physical discomfort, and to experience marked psychological distress when his chest is visible or noticed by others"].

The nature of the surgical procedure and techniques available
The expected outcomes, including chest masculinization and scar placement
The potential risks and complications, including changes to nipple sensation
The permanence and irreversibility of the procedure
The post-operative recovery requirements
The alternatives to surgery (continued binding, choosing not to pursue surgery)

[Patient Name] has made an informed, autonomous decision to pursue chest masculinization surgery.

[If patient is a minor with parental consent, adjust this section accordingly and note parental/guardian involvement and consent.]

[If no significant mental health concerns:] [Patient Name] does not have any mental health conditions that would impair [his/their] ability to consent to or recover from surgery.

It is notable that [his/their] chest dysphoria is a significant contributor to [his/their] psychological distress. [If applicable: "His anxiety and depression symptoms are directly exacerbated by chest dysphoria, and I offer, only if supported by the completed current-authority fields above, the following limited case-specific clinical opinion about his overall mental health following surgery."]

[Requester criterion: hormone history, duration, anatomy, or treatment information—quote the exact current requirement if it applies.] [Choose the appropriate option:]

[If not on hormone therapy:] [Patient Name] [has chosen not to pursue / has not yet begun / has a medical contraindication to] hormone therapy. [Current hormone-related criterion or authority for the requested chest procedure — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.] [Patient Name]'s decision regarding hormones is consistent with [his/their] gender identity and treatment goals. [He/They] has made an informed decision to pursue chest surgery [prior to / independent of] hormone therapy.

[If nonbinary patient not pursuing hormones:] As a nonbinary individual, [Patient Name] desires chest masculinization but does not desire the other effects of testosterone therapy. [Current authority and case record for a hormone-related or outcome statement — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.] [his/their] dysphoria.

[Requester criterion 6: quote the exact current requirement. The former generic prompt “Impact of chest dysphoria” is only an example and must not be treated as a universal requirement.] [Patient Name]'s chest dysphoria significantly impacts [his/their] quality of life. [Describe specific impacts, such as:]

[He/They] has been binding [his/their] chest for [duration], which causes [physical discomfort / breathing difficulty / skin irritation / rib pain]
[He/They] avoids [activities—swimming, gym, intimate situations, certain clothing]
[He/They] experiences distress when [his/their] chest is visible or perceived by others
[His/Their] chest dysphoria contributes to [social isolation / anxiety / depression / avoidance behaviors]

Chest masculinization surgery is [requester-specific medical-necessity opinion, only if requested and clinically supported] to alleviate this dysphoria and allow [Patient Name] to live authentically.

Recommendation#

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Contact Information#

Please do not hesitate to contact me if you require additional information.

Sincerely,

[Signature]

[Provider Name], [Credentials] [Title] [Practice Name] [Address] [Phone] [Email] [License Number and State] [NPI Number, if applicable]

Checklist for Providers#

Ensure your letter includes:

Your full credentials and license number
Your qualifications to write this letter
Duration and nature of clinical relationship
DSM-5 or ICD-11 diagnosis
Assessment of each exact current requester / payer / program criterion, with policy/form version and date
Specific description of chest dysphoria and its impact
Confirmation of informed consent capacity
Discussion of any mental health conditions and their management
[Only if requested] hormone-related information responsive to the exact current requester criterion, policy/form version, date, procedure, and jurisdiction
Clear statement of support/recommendation
Your contact information
Date and signature

Notes for Patients#

Confirm the current request. [Current top-surgery documentation, authority, and coverage record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Use current, procedure-specific evidence only for its stated scope; do not infer universal safety, efficacy, eligibility, hormone, or coverage rules.
The letter may describe the patient’s stated identity and clinician-supported experience only as relevant to an exact current requester criterion.
Include any binding-related fact only if it is documented and responsive to that criterion.

Appendix O: WPATH Letter Template for Hysterectomy and Oophorectomy#

Requesting-Program Documentation Overview#

Special Considerations#

[Current hysterectomy/oophorectomy procedure and care-plan record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

State only the exact requested procedure, current surgical-team plan, documented goals, alternatives, and any current requester criterion. Do not describe a sequencing, hormone, or procedural relationship as universal.

Template Letter#

[Provider Letterhead]

[Date]

Re: Letter of Support for Gender-Affirming Surgery (Hysterectomy and Oophorectomy) Patient: [Patient Legal Name] Date of Birth: [DOB] Requested Procedure: [Total hysterectomy / Total hysterectomy with bilateral salpingo-oophorectomy / Bilateral oophorectomy only—specify as applicable]

To Whom It May Concern:

I am writing at the request of [surgeon / payer / program] to address its written-documentation criteria for [exact hysterectomy / oophorectomy procedure], if written documentation is required. The requester’s current criteria are [policy / form / version / date], and this letter addresses only the items listed there.

Provider Qualifications#

Clinical Relationship#

Requester-Specified Diagnosis / Classification (only if required)#

Requesting Program / Payer Criteria Assessment#

[Requester criterion 1: quote the exact current requirement. The former generic prompt “Persistent, well-documented gender incongruence” is only an example and must not be treated as a universal requirement.] [Patient Name] has experienced gender incongruence since [approximate age/timeframe]. [He/They] identifies as [man / transmasculine / nonbinary / patient's stated identity] and has consistently expressed this identity for [duration].

[He/They] experiences dysphoria related to [his/their] internal reproductive organs and their associated functions. [Describe specific dysphoria—e.g., "The presence of a uterus and ovaries is deeply incongruent with his gender identity. Menstruation, when it occurs, causes significant psychological distress. The knowledge that these organs exist causes ongoing dysphoria even when their function is suppressed by testosterone."]

The nature of the proposed procedure(s) and surgical approach (laparoscopic, abdominal, vaginal)
The permanence and irreversibility of the procedure
The impact on fertility (permanent inability to become pregnant or carry a pregnancy)
[If oophorectomy included:] [Current surgical-team/endocrine plan, patient-specific contraindications, monitoring, and dated authority for post-operative hormone-related counseling]
The potential risks and complications of surgery
The alternatives, including continued hormone therapy without surgery
[If applicable:] How this procedure relates to planned future surgeries (metoidioplasty, phalloplasty)

[Patient Name] has made an informed, autonomous decision to pursue this surgery.

[If no significant mental health concerns:] [Patient Name] does not have any mental health conditions that would impair [his/their] ability to consent to or recover from surgery.

[Requester criterion: hormone history, duration, anatomy, or treatment information—quote the exact current requirement if it applies.] [Choose the appropriate option:]

[If on hormone therapy:] [Patient Name] has been receiving masculinizing hormone therapy (testosterone) under the supervision of [prescriber name/practice] since [date], a duration of [X months/years]. [He/They] tolerates testosterone well and plans to continue hormone therapy following surgery.

[If not currently on hormone therapy but will start after oophorectomy:] [Patient Name] is not currently on hormone therapy but understands that [he/they] has [a current, patient-specific post-operative hormone-related plan and authority, if applicable]. [He/They] has discussed this with [his/their] medical provider and has a plan in place.

[If on hormone therapy but testosterone has not fully suppressed menstruation:] Despite testosterone therapy, [Patient Name] continues to experience [breakthrough bleeding / irregular menstruation], which causes significant dysphoria. The clinician may state only [the patient-specific documented effect relevant to the exact procedure], supported by the current surgical-team record; do not predict an outcome.

[Requester criterion 6: quote the exact current requirement. The former generic prompt “Fertility considerations” is only an example and must not be treated as a universal requirement.] [Patient Name] understands that [hysterectomy / oophorectomy / both] will result in permanent inability to become pregnant or carry a pregnancy. [Choose appropriate option:]

[If patient has completed fertility preservation:] [He/They] has completed fertility preservation ([eggs frozen / embryos frozen / other]) and is prepared to proceed with surgery.

[If patient has chosen not to preserve fertility:] [He/They] has considered fertility preservation options and has made an informed decision not to pursue them. [He/They] understands and accepts the permanent impact on fertility.

[If fertility preservation is not relevant to patient's goals:] Pregnancy and biological parenthood [are not goals for this patient / are not relevant to this patient's life plans]. [He/They] has made a fully informed decision understanding the permanence of this procedure.

[Requester criterion 7: quote the exact current requirement. The former generic prompt “Specific goals for surgery” is only an example and must not be treated as a universal requirement.] [Patient Name] is pursuing [hysterectomy and oophorectomy / hysterectomy / oophorectomy] to: [Select all that apply and elaborate:]

Eliminate dysphoria associated with having internal reproductive organs
Permanently stop menstruation
[If oophorectomy:] Eliminate the need for testosterone to suppress ovarian function
[If part of surgical plan:] Prepare for future genital surgery (metoidioplasty/phalloplasty)
Align [his/their] internal anatomy with [his/their] gender identity

Recommendation#

[Patient Name] has demonstrated informed decision-making regarding fertility implications, hormone requirements, and surgical risks. [He/They] has the psychological stability and support systems responsive to the exact current requester criterion; no surgical outcome is predicted.

Contact Information#

Please do not hesitate to contact me if you require additional information.

Sincerely,

[Signature]

[Provider Name], [Credentials] [Title] [Practice Name] [Address] [Phone] [Email] [License Number and State] [NPI Number, if applicable]

Checklist for Providers#

Ensure your letter includes:

Your full credentials and license number
Your qualifications to write this letter
Duration and nature of clinical relationship
DSM-5 or ICD-11 diagnosis
Assessment of each exact current requester / payer / program criterion, with policy/form version and date
Specific description of dysphoria related to reproductive organs
Confirmation of informed consent, especially regarding fertility
Discussion of hormone therapy (current status and post-surgical plan)
Discussion of any mental health conditions and their management
Clear statement of support/recommendation
Your contact information
Date and signature

Notes for Patients#

Confirm current coverage and documentation. [Current hysterectomy/oophorectomy coverage and documentation record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Include fertility counseling, hormone-related planning, or future-procedure information only if it is clinically supported and required by the current requester or relevant to the patient’s current plan.
Do not infer coverage, counseling, treatment, or sequencing requirements from this template.

Appendix P: WPATH Letter Template for Standalone Orchiectomy#

Requesting-Program Documentation Overview#

Special Considerations for Standalone Orchiectomy#

[Current standalone orchiectomy procedure and care-plan record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

State only the patient-specific reason, exact proposed procedure, surgical-team plan, alternatives, and requester criterion supported by current records. Do not treat indications, invasiveness, recovery, or future options as universal.

Template Letter#

[Provider Letterhead]

[Date]

Re: Letter of Support for Gender-Affirming Surgery (Bilateral Orchiectomy) Patient: [Patient Legal Name] Date of Birth: [DOB] Requested Procedure: Bilateral orchiectomy (standalone, not as part of vaginoplasty)

To Whom It May Concern:

I am writing at the request of [surgeon / payer / program] to address its written-documentation criteria for [bilateral orchiectomy], if written documentation is required. The requester’s current criteria are [policy / form / version / date], and this letter addresses only the items listed there.

Provider Qualifications#

Clinical Relationship#

Requester-Specified Diagnosis / Classification (only if required)#

Requesting Program / Payer Criteria Assessment#

[Requester criterion 1: quote the exact current requirement. The former generic prompt “Persistent, well-documented gender incongruence” is only an example and must not be treated as a universal requirement.] [Patient Name] has experienced gender incongruence since [approximate age/timeframe]. [She/They] identifies as [woman / transfeminine / nonbinary / patient's stated identity] and has consistently expressed this identity for [duration].

[She/They] experiences dysphoria related to [her/their] testicles and the testosterone they produce. [Describe specific dysphoria—e.g., "The presence of testicles is deeply incongruent with her gender identity. She experiences distress from their physical presence and from the ongoing production of testosterone, which requires continuous medical suppression."]

[Current surgical-team discussion for the exact procedure: approach, fertility implications, hormone-related plan, tissue/future-procedure considerations, risks, alternatives, recovery, and limitations]
[Patient-specific documented understanding of that discussion]

[Patient Name] has made an informed, autonomous decision to pursue orchiectomy as a standalone procedure.

[If no significant mental health concerns:] [Patient Name] does not have any mental health conditions that would impair [her/their] ability to consent to or recover from surgery.

[Requester criterion: hormone history, duration, anatomy, or treatment information—quote the exact current requirement if it applies.] [Patient Name] has been receiving feminizing hormone therapy under the supervision of [prescriber name/practice] since [date], a duration of [X months/years]. [She/They] is currently taking [estrogen and anti-androgens / specify regimen].

Following orchiectomy, [she/they] has [a current, patient-specific medication plan from the prescribing/surgical team, if applicable]. [She/They] understands the importance of continuing hormone therapy after gonadectomy and has discussed this with [her/their] prescribing provider.

[Requester criterion 6: quote the exact current requirement. The former generic prompt “Rationale for standalone orchiectomy” is only an example and must not be treated as a universal requirement.] [Patient Name] is pursuing orchiectomy as a standalone procedure rather than as part of vaginoplasty because:

[Select and elaborate on applicable reasons:]

[She/They] does not desire vaginal construction at this time [or at all]
[She/They] wishes to eliminate testosterone production and discontinue anti-androgen medications, which [cause side effects / are costly / require ongoing management]
[She/They] desires a less invasive procedure with shorter recovery time
[She/They] has medical factors that make orchiectomy preferable to more extensive surgery at this time
[If nonbinary:] [Her/Their] gender identity and embodiment goals do not include vaginal construction
[If considering future vaginoplasty:] [She/They] wishes to proceed with orchiectomy now while continuing to consider options for future surgery

This is a thoughtful, well-considered decision that reflects [her/their] specific goals and circumstances.

[Requester criterion 7: quote the exact current requirement. The former generic prompt “Fertility considerations” is only an example and must not be treated as a universal requirement.] [Patient Name] understands that bilateral orchiectomy will result in permanent inability to produce sperm. [Choose appropriate option:]

[If patient has completed fertility preservation:] [She/They] has completed fertility preservation (sperm banking) and is prepared to proceed with surgery.

[If patient has chosen not to preserve fertility:] [She/They] has considered fertility preservation options and has made an informed decision not to pursue them. [She/They] understands and accepts the permanent impact on fertility.

Recommendation#

[Patient Name] has demonstrated informed decision-making, a clear rationale for choosing orchiectomy as a standalone procedure, and the psychological stability responsive to the exact current requester criterion; no surgical outcome is predicted.

Contact Information#

Please do not hesitate to contact me if you require additional information.

Sincerely,

[Signature]

[Provider Name], [Credentials] [Title] [Practice Name] [Address] [Phone] [Email] [License Number and State] [NPI Number, if applicable]

Checklist for Providers#

Ensure your letter includes:

Your full credentials and license number
Your qualifications to write this letter
Duration and nature of clinical relationship
DSM-5 or ICD-11 diagnosis
Assessment of each exact current requester / payer / program criterion, with policy/form version and date
Patient's rationale for choosing standalone orchiectomy
Confirmation of informed consent, including fertility implications
Discussion of hormone therapy (current and post-surgical plan)
Discussion of any mental health conditions and their management
Clear statement of support/recommendation
Your contact information
Date and signature

Notes for Patients#

Confirm the current procedure and access record. [Current standalone-orchiectomy authority, surgical plan, and coverage/documentation record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Discuss future procedures, specialty availability, medication plans, and patient goals only with the current surgical/prescribing team and the current requester’s criteria. Do not infer universal eligibility, access, benefit, or future-procedure effects.

Appendix Q: WPATH Letter Template for Facial Feminization/Masculinization Surgery#

Requesting-Program Documentation Overview#

[Current facial-surgery documentation and coverage record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Obtain the named requester’s current criteria before using this template. Do not infer a SOC8 letter rule, payer coverage practice, consent process, or number of letters.

Special Considerations for FFS/FMS#

[Current FFS/FMS procedure list and surgical-plan record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

The following examples are not a universal procedure set; list only components currently proposed by the surgical team:

Facial Feminization Surgery (FFS):

Forehead contouring/reduction
Brow lift
Rhinoplasty
Cheek augmentation
Lip lift/augmentation
Jaw contouring/reduction
Chin reshaping (genioplasty)
Tracheal shave (chondrolaryngoplasty)
Hairline advancement

Facial Masculinization Surgery (FMS):

Forehead augmentation
Brow bone enhancement
Rhinoplasty
Cheek augmentation/reduction
Jaw augmentation
Chin augmentation
Adam's apple enhancement

The letter should address the patient's specific facial dysphoria and how it impacts their daily life, particularly regarding social recognition and safety.

Template Letter#

[Provider Letterhead]

[Date]

Re: Letter of Support for Gender-Affirming Surgery (Facial [Feminization/Masculinization] Surgery) Patient: [Patient Legal Name] Date of Birth: [DOB] Requested Procedure: Facial [Feminization/Masculinization] Surgery, including [list specific procedures if known]

To Whom It May Concern:

I am writing at the request of [surgeon / payer / program] to address its current written-documentation criteria for [exact facial procedure/components], if documentation is required. [Current facial-surgery requester criterion and authority — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.] This letter addresses only the listed, clinician-supported items and is not an approval or universal eligibility conclusion.

Provider Qualifications#

Clinical Relationship#

Requester-Specified Diagnosis / Classification (only if required)#

Medical Necessity of Facial Surgery#

Facial [feminization/masculinization] surgery is [requester-specific medical-necessity opinion, only if requested and clinically supported] for [Patient Name] for the following reasons:

[Requester criterion 1: quote the exact current requirement. The former generic prompt “Facial dysphoria causes significant distress” is only an example and must not be treated as a universal requirement.] [Patient Name] experiences marked dysphoria related to [her/his/their] facial features, which [she/he/they] perceives as incongruent with [her/his/their] gender identity. The clinician may state only [the patient-specific, documented impact and response to interventions] that is relevant to [the exact current requester criterion].

[Describe specific facial features causing dysphoria—e.g., "She experiences particular distress related to her brow ridge, jaw, and chin, which she perceives as masculine features incongruent with her identity as a woman."]

[Requester criterion 2: quote the exact current requirement. The former generic prompt “Facial appearance impacts social recognition and safety” is only an example and must not be treated as a universal requirement.] [Current authority or patient-specific record for any social-recognition or safety statement — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.] [Patient Name]'s current facial features result in [frequent misgendering / difficulty being recognized as [her/his/their] gender / significant distress in social situations].

[Describe impact—e.g., "Despite several years of hormone therapy and social transition, she continues to be frequently misgendered in public interactions. This causes significant distress, triggers dysphoria, and impacts her ability to navigate daily life with confidence. She reports anxiety about public spaces and avoids situations where she may be misgendered."]

[If applicable for transfeminine patients:] Being visibly transgender also creates safety concerns. [Patient Name] has experienced [describe any harassment, discrimination, or safety incidents if applicable and patient consents to share]. The clinician may state only [a patient-specific, documented safety concern and the limited current clinical opinion, if any], without predicting safety outcomes.

[Requester criterion 3: quote the exact current requirement. The former generic prompt “Hormone therapy alone is insufficient” is only an example and must not be treated as a universal requirement.] [For FFS:] [Current, procedure-specific surgical-team or clinical authority about the patient’s relevant anatomy and treatment history; do not state a universal hormone effect.] [Patient Name]'s facial dysphoria is related to [bony structures / features that require a current, procedure-specific surgical-team assessment].

[For FMS:] [Current, procedure-specific surgical-team or clinical authority about the patient’s relevant anatomy and treatment history; do not state a universal hormone effect.] [Patient Name] continues to experience dysphoria related to [specific features] that are not adequately addressed by testosterone alone.

[Requester criterion 4: quote the exact current requirement. The former generic prompt “Impact on mental health and functioning” is only an example and must not be treated as a universal requirement.] [Patient Name]'s facial dysphoria significantly impacts [her/his/their]:

Daily functioning: [describe—avoidance behaviors, difficulty with work/school, social isolation]
Mental health: [describe—anxiety, depression, distress related to appearance]
Quality of life: [describe—inability to live authentically, constant awareness of facial features]

[If applicable:] [Her/His/Their] depression and anxiety symptoms are directly exacerbated by facial dysphoria and the social consequences of being misgendered. I offer, only if supported by the completed current-authority fields above, the following limited case-specific clinical opinion about [her/his/their] overall mental health following facial surgery.

Assessment of Readiness#

Capacity to consent: [Patient Name] demonstrates clear understanding of the proposed procedures, expected outcomes, potential risks and complications, and realistic limitations of surgery. [She/He/They] has researched facial surgery extensively and consulted with [her/his/their] surgical team.

Mental health stability: [Choose appropriate option:]

[If no significant mental health concerns:] [Patient Name] does not have any mental health conditions that would impair [her/his/their] ability to consent to or recover from surgery.

Realistic expectations: [Patient Name] has realistic expectations about surgical outcomes. [She/He/They] understands that surgery will alter [her/his/their] appearance to be more congruent with [her/his/their] gender identity, but will not result in a completely different face. [She/He/They] has reviewed before-and-after photos and discussed expected outcomes with [her/his/their] surgeon.

Hormone history (only if requester asks): [For FFS, only if requested:] [Current hormone history and surgical-team assessment for the exact facial procedure — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

[For FMS:] [Patient Name] has been receiving masculinizing hormone therapy since [date], a duration of [X months/years].

[If not on hormones:] [Patient Name] [has chosen not to pursue / has a contraindication to] hormone therapy. [Current hormone-related criterion and surgical-team assessment — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.] [her/his/their] facial dysphoria is related to features that are primarily addressed surgically regardless of hormone status.

Specific Procedures Recommended#

[If specific procedures are identified, list them:] Based on consultation with [surgeon name], the following procedures have been recommended:

[List procedures—e.g., forehead contouring, rhinoplasty, jaw reduction, etc.]

These procedures collectively address [Patient Name]'s facial dysphoria and are [requester-specific medical-necessity opinion, only if requested and clinically supported] as part of [her/his/their] gender-affirming care.

Recommendation#

[Patient Name] has demonstrated the psychological stability, realistic expectations, and informed decision-making responsive to the exact current requester criterion; no surgical outcome is predicted.

Contact Information#

Please do not hesitate to contact me if you require additional information.

Sincerely,

[Signature]

[Provider Name], [Credentials] [Title] [Practice Name] [Address] [Phone] [Email] [License Number and State] [NPI Number, if applicable]

Checklist for Providers#

Ensure your letter includes:

Your full credentials and license number
Your qualifications to write this letter
Duration and nature of clinical relationship
DSM-5 or ICD-11 diagnosis
Specific description of facial dysphoria and which features cause distress
Impact on daily functioning, mental health, and quality of life
Discussion of social recognition, misgendering, and safety (as applicable)
Explanation of why hormone therapy alone is insufficient
Hormone therapy status
Assessment of capacity, realistic expectations, and mental health stability
Specific procedures if known
Clear statement of medical necessity and recommendation
Your contact information
Date and signature

Notes for Patients#

Confirm the current payer and procedure record. [Current facial-surgery coverage, authorization, and authority record — complete before using this text:

Requester: [Exact surgeon, payer, or program]
Payer: [Exact payer/plan administrator, or “not applicable”]
Requested procedure: [Exact procedure and components]
Jurisdiction: [Governing state/federal/other jurisdiction]
Current authority: [Current requester policy/form, surgical-team plan, clinical record, or official authority; issuer, title/version, effective/retrieved date, URL/attachment]
Limited supported statement: [Exact, case-specific statement and record/authority pinpoint] Use only the limited statement that the named current authority supports; omit this item if these fields cannot be completed.]

Document only patient-specific facts and clinician-supported opinions relevant to the exact current criterion.
Ask the requester whether individual components need separate review or authorization; do not infer coverage, medical necessity, classification, or appeal outcome from this template.

Sample Language for Specific Situations#

For patients who experience harassment or safety concerns: "[Patient Name] reports experiencing verbal harassment and threats in public spaces when perceived as transgender. She has modified her daily routines to avoid situations where she feels unsafe. Any current clinical opinion must be limited to documented, patient-specific concerns and the exact requested procedure; it must not predict visibility or safety outcomes."

For patients whose mental health is significantly impacted: "[Patient Name]'s facial dysphoria is a primary driver of her depression and anxiety. She avoids mirrors, photographs, and video calls. She has declined professional opportunities that would require public visibility. Her facial dysphoria significantly impairs her functioning in multiple life domains ; any current clinical opinion must be limited to the documented case record and the exact procedure-specific surgical-team assessment."

This template reflects current standards of care. Requirements vary by surgeon, insurance company, and jurisdiction. Always confirm specific requirements with your surgical team and insurance.