Policy: Gender Affirming Services (Transgender Services)
Policy Number: 189
Last Update: 2021-10
Issued in: Massachusetts

Breast Reconstruction:

Breast augmentation for transfeminine members may be considered MEDICALLY NECESSARY when ALL of the following candidate criteria are met:

• Age ≥ 18,
• The candidate has been diagnosed with gender dysphoria (ICD-10 codes F64.0-F64.9 gender identity disorder), including meeting ALL of the following indications:
  • The desire to live and be accepted as a member of another gender other than one’s assigned
    sex, typically accompanied by the desire to make the physical body as congruent as possible
    with the identified gender through surgery and hormone treatment.
  • The new gender identity has been present for at least 12 months.
  • The member has a consistent, stable gender identity that is well documented by their treating
    providers, and when possible, lives as their affirmed gender in places where it is safe to do
    so.
  • The gender dysphoria (ICD-10 codes F64.0-F64.9 gender identity disorder) is not a symptom
    of another mental disorder.
• For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is provided under the supervision of a licensed clinician.

Facial Reconstruction:

Facial Procedures

Facial feminization or masculinization may be considered MEDICALLY NECESSARY when ALL of the following criteria are met:

• Age ≥ 18
• The member has been diagnosed with gender dysphoria (ICD-10 codes F64.0-F64.9 gender identity disorder), including meeting ALL of the following indications:
  • The desire to live and be accepted as a member of another gender other than one’s assigned sex, typically accompanied by the desire to make the physical body as congruent as possible with the identified gender through surgery and hormone treatment
  • The new gender identity should be present for at least 12 months.
  • The member has a consistent, stable gender identity that is well documented by their treating providers, and when possible, lives as their affirmed gender in places where it is safe to do so.
  • The gender dysphoria (ICD-10 codes F64.0-F64.9 gender identity disorder) is not a symptom of another mental disorder.
• Covered procedures when medical necessity criteria are met:
  • Forehead contouring
  • Rhinoplasty
  • Mandible reconstruction
  • Trachea shave
  • Blepharoplasty
  • Brow lift
  • Cheek augmentation
  • Face lift or liposuction (only as needed in conjunction with one of the above procedures).
• The following facial procedures are considered INVESTIGATIONAL and are not covered:
  • Lip enhancement
  • Neck lift
  • Dermabrasion
  • Chemical peel
  • Hair transplant
  • Electrolysis (except for genital surgery as noted below)
  • Vocal cord surgery.

Fertility Preservation:

Oocyte, embryo, or sperm retrieval, freezing and storage for up to 24 months for transgender members prior to undergoing hormone therapy or genital sex reassignment surgery may be considered MEDICALLY NECESSARY. (See medical policy #086, Infertility Diagnosis and Treatment)

• Per subscriber certificate language, cryopreservation is limited to one cycle only.

Permanent Hair Removal:

Electrolysis performed by a licensed dermatologist may be considered MEDICALLY NECESSARY for the removal of hair on a skin graft donor site prior to its use in genital gender affirmation surgery.

Youth Services:

Puberty Blockers

Gonadotropin-releasing hormone (GnRH) analog treatment for gender non-conforming adolescents seeking to delay puberty is covered at the discretion of the treating provider*. GnRH analogs may be used to either allow patients more time for decision making purposes or as an initial step prior to further gender affirming services such as hormone replacement.

Treatment options include but are not limited to:

• Lupron
• Supprelin LA
• Vantas
• Triptodur (triptorelin).

Surgical Services for Adolescents

Members < 18 years of age will be considered on a case-by-case basis.

In addition to meeting all of the above criteria, providers requesting surgery for members < 18 will need to provide documentation supporting all of the following:

• The member has been evaluated for safety.
• The member has adequate home support.
• The member has realistic expectations regarding the possibilities and limitations of surgery and a full understanding of the long-term consequences of surgical procedures.
• The member has been assessed for any co-existing mental health concerns and is not requesting surgery as an initial response to gender dysphoric puberty.