Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services
Policy Number: SUR717.001
Last Update: 2021-01-15
Issued in: Oklahoma

Facial Reconstruction:

F. Secondary Sexual Characteristic (Masculinizing or Feminizing) Gender Reassignment Surgeries and Related Services:

Procedures or services to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment services treatment plan may be considered medically necessary for the treatment of gender dysphoria ONLY. These procedures may include the following:

• Abdominoplasty;
• Blepharoplasty;
• Brow lift;
• Calf implants;
• Cheek implants;
• Chin or nose implants;
• External penile prosthesis (vacuum erection devices);
• Face lift (rhytidectomy);
• Facial bone reconstruction/sculpturing/reduction, includes jaw shortening;
• Forehead lift or contouring;
• Hair removal (may include donor skin sites) or hair transplantation (electrolysis or hairplasty);
• Laryngoplasty;
• Lip reduction or lip enhancement;
• Liposuction/lipofilling or body contouring or modeling of waist, buttocks, hips, and thighs reduction;
• Neck tightening;
• Pectoral implants;
• Reduction thyroid chondroplasty or trachea shaving (reduction of Adam’s apple);
• Redundant/excessive skin removal;
• Rhinoplasty (nose correction);
• Skin resurfacing;
• Testicular expanders;
• Voice modification surgery; and/or
• Voice (speech) therapy or voice lessons.

NOTE 4: Preparatory or ancillary procedures (such as anesthesia, tissue harvesting for skin, fat, nerve or muscle grafting, etc.) and supplies or equipment (such as stents, prosthesis, implants, etc.) that are required for the procedures listed above are considered an integral part of the MtF or FtM transition process.

NOTE 5: Surgical repairs or revisions related to MtF or FtM procedures may be required, such as removal and replacement of prostheses.

Voice Therapy and Surgery:

Procedures or services to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment services treatment plan may be considered medically necessary for the treatment of gender dysphoria ONLY. These procedures may include the following:

• Laryngoplasty
• Voice modification surgery; and/or
• Voice (speech) therapy or voice lessons.

Youth Services:

A. Gender Reassignment Surgery and Related Services for Children and Adolescents:

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

• Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);
• Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or
• Chest surgery for female-to-male (FtM) individuals.

The individual being considered for surgery and related services must meet ALL the following criteria. The individual must have:

• Been diagnosed with persistent, well-documented gender dysphoria; and
• The required referrals prior to any surgery or related service(s):
  • Prior to feminizing or masculinizing hormonal therapy, one required referral from the individual’s qualified mental health professional (see NOTE 2) competent in the assessment and treatment of gender dysphoria; and/or
  • Prior to breast/chest surgery, e.g., mastectomy, chest reconstruction, or breast augmentation, one required referral from the individual’s qualified mental health professional (see NOTE 2) competent in the assessment and treatment of gender dysphoria.

NOTE 1: The 2012 World Professional Association for Transgender Health (WPATH) Version 7, Standards of Care (SOC) (6) state that adolescent individuals seeking irreversible interventions, such as genital surgery:

“Genital surgery should not be carried out until (i) patients reach the legal age of majority to give consent for medical procedures in a given country, and (ii) patients have lived continuously for at least 12 months in the gender role that is congruent with the gender identity. The age threshold should be seen as a minimum criterion and not an indication in and of itself for active intervention.”

Notes:

B. Criteria for Coverage of Gender Reassignment Surgery and Related Services for Adults:

The individual being considered for surgery and related services must meet ALL the following criteria. The individual must have:

• Reached the age of majority; and
• The capacity to make a fully informed decision and to consent for treatment; and
• Been diagnosed with persistent, well-documented gender dysphoria; and
• The required referrals prior to any surgery or related service(s):
  • Prior to feminizing or masculinizing hormonal therapy, one required referral from the individual’s qualified mental health professional (see NOTE 2) competent in the assessment and treatment of gender dysphoria; and/or
  • Prior to breast/chest surgery, e.g., mastectomy, chest reconstruction, or breast augmentation, one required referral from the individual’s qualified mental health professional (see NOTE 2) competent in the assessment and treatment of gender dysphoria; and/or
  • Prior to any genital surgery, e.g., hysterectomy, salpingo-oophorectomy, orchiectomy, and/or other genital reconstructive procedures, two separate required independent referrals (or one signed by both referring providers) from the individual’s qualified mental health professionals (see NOTE 2) competent in the assessment, treatment of gender dysphoria, and addressing the identical/same surgery to be performed.

NOTE 2: Psychotherapy and Mental Health Services:

Psychotherapy is not required for gender reassignment services except when a mental health professional recommends psychotherapy based on initial assessment prior to gender reassignment surgery. The recommendation for psychotherapy must specify the goals of treatment along with estimates of the frequency and duration of therapy throughout the individual’s experience living in one’s affirmed gender.