Policy: Gender Reassignment Surgery
Last Update: 2020-07-24

Facial Reconstruction:

Exclusion Criteria

The following procedures are considered cosmetic and not a covered benefit include, but are not limited to:

• Feminizing procedures including Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction of hyoid (chondroplasty), hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing.

Fertility Preservation:

In addition, the following procedures are not covered:

• Procurement, cryopreservation or storage of embryo, sperm, oocytes for the preservation of fertility and the cryopreservation, storage, and thawing of reproductive tissue (i.e., ovaries, testicular tissue).

Voice Therapy and Surgery:

Exclusion Criteria

The following procedures are considered cosmetic and not a covered benefit include, but are not limited to:

• Feminizing procedures including Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction of hyoid (chondroplasty), hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing.

Notes:

Gender reassignment surgery may be covered when ALL of the following criteria are met: • Requests for mastectomy, gonadectomy, or genital reconstruction require ALL of the following:

1. At least one (1) Referral Letter from a qualified Psychologist or Psychiatrist indicating: a. Results of the Member’s psychosocial assessment and diagnoses; and b. Documentation and results of the type of evaluation and therapy or counseling to date; and c. Documentation that the World Professional Association for Transgender Health (WPATH) criteria for surgery have been met and the specific clinical rationale for supporting the Member’s request for surgery; and
2. Documentation of persistent, well-documented Gender Dysphoria (DSM 5 criteria); and
3. Documentation of Member’s capacity to make a fully informed decision and to consent for treatment; and
4. Member is 18 years of age or older; and
5. Documentation of at least 12 months of continuous hormone therapy as appropriate to the Member's gender goals (Note: that a trial of hormone therapy is not a pre- requisite to qualify for a mastectomy.); and
6. Important Note - For those Members requesting genital reconstruction: Two (2) Psychiatric Letters of Referral are needed along with documentation of at least 12 months of living in a gender role that is congruent with their gender identity (real life experience).