Policy: Gender Affirming Procedures for Gender Dysphoria
Policy Number: IV-123-007
Last Update: 2020-04-06
Issued in: Minnesota

Body Contouring:

Surgical procedures to alter the gender-specific appearance of a member who has undergone or is planning to undergo gender reassignment surgery, include but are not limited to: ...

• Liposuction

These procedures are subject to contract definitions for medical necessity and appropriateness as well as contract benefits.

Breast Reconstruction:

Breast augmentation (e.g. implants/lipofilling) may be considered MEDICALLY NECESSARY AND APPROPRIATE in male-to-female members when criteria in section I AND the following criteria are met:

• The member is at least 18 years of age (legal age of majority in Minnesota). Requests for breast surgery for a member younger than 18 years of age will be reviewed by medical director; and
• Persistent, well-documented gender dysphoria; and
• Capacity to make a fully informed decision and to give consent to treatment; and
• If significant medical or mental health concerns are present, they must be reasonably well-controlled.
• NOTE: Hormone therapy is not a prerequisite for breast augmentation for male-to-female members. The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People Version 7 from the World Professional Association for Transgender Health (WPATH) state the following: "Although not an explicit criterion, it is recommended that MtF (male-to-female) 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."

Documentation Requirements

• One letter of recommendation must be provided to a health plan representative from a qualified mental health professional. The letter must address ALL of the following:
  1. The member's general identifying characteristics; and
  2. Results of the member's psychosocial assessment, including any diagnoses; and
  3. The duration of the mental health professional's relationship with the member including the type of evaluation and therapy or counseling to date; and
  4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the member's request for surgery; and
  5. A statement about the fact that informed consent has been obtained from the patient; and
  6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

• The health plan and the physician responsible for breast removal or augmentation must receive this letter and recommendations for surgery and the surgical treatment must be authorized by the health plan prior to its occurrence. If the providers are working within a multidisciplinary specialty team, the letters may be sent only to the health plan with documentation of the information in the member's chart.

Facial Reconstruction:

• The following procedures for the treatment of gender dysphoria may be considered MEDICALLY NECESSARY AND APPROPRIATE to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment treatment plan when criteria in section I are met:
  • Reduction thyroid chondroplasty or trachea shaving (reduction of Adam’s apple);

• Documentation Requirements:
  
  • One letter of recommendation from a qualified mental health professional (as defined in section I) has been obtained and includes ALL of the following:
    
    • The member’s general identifying characteristics; and
    • Results of the member’s psychosocial assessment, including any diagnoses; and
    • The duration of the mental health professional’s relationship with the member including the type of evaluation and therapy or counseling to date; and
    • An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the member’s request for surgery; and
    • A statement about the fact that informed consent has been obtained from the patient; and
    • A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.
  • The letter must be presented to the health plan and to the surgeon prior to surgery. If the providers are working within a multidisciplinary specialty team, the letters may be sent only to the health plan with documentation of the information in the patient's chart.
  • For voice modification surgery, documentation from the treating speech therapy provider that speech therapy was tried and failed, and that voice modification surgery will provide further benefit.

The following procedures and criteria for coverage are addressed in separate medical policies:

• Rhinoplasty (see policy IV-73;
• Blepharoplasty (see policy IV-17).

Fertility Preservation:

Preservation of fertility is subject to the member’s contract benefits. This includes but is not limited to procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue.

Permanent Hair Removal:

• The following procedures for the treatment of gender dysphoria may be considered MEDICALLY NECESSARY AND APPROPRIATE to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment treatment plan when criteria in section I are met:
  • Electrolysis or laser treatment for facial hair removal;

• Documentation Requirements:
  
  • One letter of recommendation from a qualified mental health professional (as defined in section I) has been obtained and includes ALL of the following:
    
    • The member’s general identifying characteristics; and
    • Results of the member’s psychosocial assessment, including any diagnoses; and
    • The duration of the mental health professional’s relationship with the member including the type of evaluation and therapy or counseling to date; and
    • An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the member’s request for surgery; and
    • A statement about the fact that informed consent has been obtained from the patient; and
    • A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.
  • The letter must be presented to the health plan and to the surgeon prior to surgery. If the providers are working within a multidisciplinary specialty team, the letters may be sent only to the health plan with documentation of the information in the patient's chart.
  • For voice modification surgery, documentation from the treating speech therapy provider that speech therapy was tried and failed, and that voice modification surgery will provide further benefit.

Voice Therapy and Surgery:

• The following procedures for the treatment of gender dysphoria may be considered MEDICALLY NECESSARY AND APPROPRIATE to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment treatment plan when criteria in section I are met:
  • Voice therapy;
  • Voice modification surgery when voice/speech therapy has been ineffective;

• Documentation Requirements:
  
  • One letter of recommendation from a qualified mental health professional (as defined in section I) has been obtained and includes ALL of the following:
    
    • The member’s general identifying characteristics; and
    • Results of the member’s psychosocial assessment, including any diagnoses; and
    • The duration of the mental health professional’s relationship with the member including the type of evaluation and therapy or counseling to date; and
    • An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the member’s request for surgery; and
    • A statement about the fact that informed consent has been obtained from the patient; and
    • A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.
  • The letter must be presented to the health plan and to the surgeon prior to surgery. If the providers are working within a multidisciplinary specialty team, the letters may be sent only to the health plan with documentation of the information in the patient's chart.
  • For voice modification surgery, documentation from the treating speech therapy provider that speech therapy was tried and failed, and that voice modification surgery will provide further benefit.