Policy: Gender Affirming Surgery
Policy Number: CG-SURG-27
Last Update: 2021-05-20

Permanent Hair Removal:

The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary.

Voice Therapy and Surgery:

Gender affirming voice modification surgery is considered reconstructive when all of the following criteria have been met:

1. The individual is at least 18 years of age; and
2. The individual has capacity to make fully informed decisions and consent for treatment; and
3. The individual has been diagnosed with gender dysphoria (see Discussion section for diagnostic criteria); and
4. For gender masculinization only: for individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and
5. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
6. Existing vocal presentation demonstrates significant variation from normal for the experienced gender; and
7. One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission.

Cosmetic and Not Medically Necessary:

The following procedures, when requested alone or in combination with other procedures, are considered cosmetic and not medically necessary when applicable reconstructive criteria above have not been met, or when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender affirming surgery, including, but not limited to, the following:

1. Abdominoplasty
2. Bilateral mastectomy
3. Blepharoplasty
4. Breast augmentation
5. Brow lift
6. Calf implants
7. Face lift
8. Facial bone reconstruction
9. Facial implants
10. Gluteal augmentation
11. Hair removal (for example, electrolysis or laser) and hairplasty, when the criteria above have not been met
12. Jaw reduction (jaw contouring)
13. Lip reduction/enhancement
14. Lipofilling/collagen injections
15. Liposuction
16. Nose implants
17. Pectoral implants
18. Rhinoplasty
19. Thyroid cartilage reduction (chondroplasty)
20. Voice modification surgery

Notes:

Reconstructive

Gender affirming chest surgery (augmentation, mastectomy, or reduction) is considered reconstructive when all of the following criteria have been met:

1. The individual is at least 18 years of age (see Further Considerations section below for individuals under 18 years of age); and
2. The individual has capacity to make fully informed decisions and consent for treatment; and
3. The individual has been diagnosed with gender dysphoria (see Discussion section for diagnostic criteria); and
4. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
5. For gender affirming breast augmentation procedures only: for individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician, and insufficient breast development has occurred; and
6. Existing chest appearance demonstrates significant variation from normal appearance for the experienced gender (note: each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive); and
7. One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission.

Nipple reconstruction, including tattooing, following a gender affirming mastectomy that meets the reconstructive criteria above is considered reconstructive.