Policy: Gender Affirming Procedures
Policy Number: 024
Last Update: 2021-05
Issued in: Massachusetts

This policy applies to Medicaid

Breast Reconstruction:

AllWays Health Partners covers the following procedures for Male to Female: ... Augmentation Mammoplasty

AllWays Health Partners covers mastectomy, breast augmentation, and nipple/areolar complex reconstruction when the requirements as noted above are met and documentation has been submitted from one qualified behavioral health provider. ... Although not an explicit criterion, it is recommended that MtF patients 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:

AllWays Health Partners covers facial feminization or masculinization when all of the following requirements are met:

1. The member is at least 18 years of age
2. The member has been diagnosed with gender dysphoria meeting DSM-V criteria by a qualified mental health professional and the diagnosis has been present for at least 6 months
3. Recommendation for the requested procedure is made by the qualified mental professional mentioned above
4. Co-morbid medical or mental health disorders are appropriately managed, reasonably controlled, and not causing symptoms of dysphoria
5. The member has capacity to make fully informed decisions and has consented to the procedure after limitations, risks, and complications of the procedure have been discussed.
6. Covered procedures when medical necessity criteria above are met:
   1. Forehead contouring (Osteoplasty)
   2. Rhinoplasty
   3. Mandible/jaw contouring- reconstruction
   4. Trachea shave or tracheoplasty
   5. Blepharoplasty (only as needed in conjunction with other facial feminization procedures)
   6. Brow lift
   7. Cheek augmentation
   8. Face lift or rhytidectomy (forehead and cheek, excluding neck) or liposuction (only as needed in conjunction with one of the above procedures)
   9. Genioplasty

Fertility Preservation:

AllWays Health Partners 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 AllWays Health Partners’ Assisted Reproductive Services/Infertility Services medical policy.

Permanent Hair Removal:

AllWays Health Partners covers hair removal with laser or electrolysis, by a board-certified dermatologist or licensed provider, when the member meets one of the following criteria for planned transgender genital surgery:

1. The defined area of hair removal is to treat tissue donor site(s) for a planned surgical phalloplasty
2. The defined area of hair removal is to treat tissue donor site(s) for a planned surgical vaginoplasty

Documentation, including a letter of medical necessity by the treating surgeon, is required which attests to plan and timeline for surgery pending completion of hair removal. Electrolysis/laser hair removal for any other part of the body is considered cosmetic and not covered.

Youth Services:

AllWays Health Partners will determine coverage of breast/chest surgeries specifically for FtM members under the age of 18 on a case by case basis, when all criteria specified above for gender affirming surgeries are met. (Commercial and Qualified Health Plans only).