Policy: Gender Affirming Procedures
Policy Number: 024
Last Update: 2023-04
Issued in: Massachusetts

This policy applies to Medicare

Breast Reconstruction:

Chest/Breast Surgeries

Mass General Brigham Health Plan covers bilateral mastectomy, breast augmentation, breast reduction (MassHealth only), chest reconstruction/contouring and nipple/areolar complex reconstruction when the requirements as noted above are met and documentation has been submitted from one qualified behavioral health provider. For transmasculine members, there is no requirement for hormone therapy. Although not an explicit criterion, it is recommended that transfeminine members undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

Facial Reconstruction:

Covered procedures when medical necessity criteria are met:

a. Forehead contouring (Osteoplasty)

b. Rhinoplasty/Septoplasty

c. Mandible/jaw contouring- reconstruction

d. Trachea shave or tracheoplasty

e. Blepharoplasty (only as needed in conjunction with other facial feminization procedures)

f. Brow lift g. Cheek augmentation

h. Rhytidectomy (Face lift) of forehead and cheek, excluding neck. Rhytidectomy is excluded for MassHealth members.

i. Genioplasty

j. Scalp (hairline) advancement

k. Lateral canthopexy

l. Lip lift

m. Lysis intranasal synechia

n. Suction-assisted lipectomy /liposuction (only as needed in conjunction with one of the above procedures).

Fertility Preservation:

Mass General Brigham Health Plan covers services related to fertility preservation in members undergoing gender affirming procedures including oocyte, embryo, or sperm retrieval, freezing and storage for up to 2 years for trans members undergoing hormonal therapy or genital affirmation surgery. Please refer to details of coverage in Mass General Brigham Health Plan’s Assisted Reproductive Services/Infertility Services medical policy.

Permanent Hair Removal:

Mass General Brigham Health Plan covers hair removal with laser or electrolysis, by a board-certified dermatologist or licensed provider for removal of hair on skin being used for genital gender affirmation surgery. Documentation, including a letter of medical necessity by the treating surgeon, is required which attests to the plan and timeline for surgery pending completion of hair removal. Reimbursement for up to 12 electrolysis and/or laser hair treatments will be approved if criteria above are met. Prior authorization is required for greater than 12 electrolysis and/or laser hair removal treatments and should include a subsequent letter of medical necessity. Electrolysis/laser hair removal for any other part of the body is considered cosmetic and not covered for commercial and QHP members.

Youth Services:

Mass General Brigham Health Plan will determine coverage of breast/chest surgeries specifically for transmasculine members under the age of 18 when all criteria specified above for gender affirming surgeries are met. These cases will be reviewed by a Medical Director for individual consideration

Notes:

Gender Affirming Covered Procedures Mass General Brigham Health Plan covers the following Transfeminine procedures:

1. Vaginoplasty

2. Orchiectomy

3. Clitoroplasty

4. Penectomy

5. Labiaplasty

6. Augmentation Mammoplasty/Breast Augmentation

7. Vulvoplasty

8. Urethroplasty

Mass General Brigham Health Plan covers the following Transmasculine procedures:

1. Vaginectomy

2. Vulvectomy

3. Urethroplasty

4. Phalloplasty

5. Metoidioplasty

6. Mastectomy

7. Scrotoplasty with insertion of testicular prosthesis

8. Hysterectomy

9. Erectile and testicular prosthesis

10. Salpingo-oophorectomy