Policy: Gender Reassignment Surgery
Policy Number: BSC7.02
Last Update: 2021-04-01
Issued in: California

Body Contouring:

Additional surgeries may be proposed (i.e., body feminization or masculinization) for an individual who is planning to undergo or has undergone gender reassignment surgery. Including, but not limited to, the following surgical procedures need to be reviewed for medical necessity (see documentation needed for medical necessity determination in the Policy Guidelines section):

• Calf implants
• Gluteal and hip augmentation (implants/lipofilling)
• Liposuction (removal of fat in the hips, thighs, or buttocks)
• Pectoral implants
• Suction-assisted lipoplasty of the waist

Breast Reconstruction:

Additional surgeries may be proposed (i.e., body feminization or masculinization) for an individual who is planning to undergo or has undergone gender reassignment surgery. Including, but not limited to, the following surgical procedures need to be reviewed for medical necessity (see documentation needed for medical necessity determination in the Policy Guidelines section):

• Breast enlargement procedures, including augmentation mammoplasty, implants, and silicone injections of the breast

Facial Reconstruction:

Additional surgeries may be proposed (i.e., body feminization or masculinization) for an individual who is planning to undergo or has undergone gender reassignment surgery. Including, but not limited to, the following surgical procedures need to be reviewed for medical necessity (see documentation needed for medical necessity determination in the Policy Guidelines section):

• Blepharoplasty/Brow reduction/brow lift (removal of redundant skin of the upper and/or lower eyelids and protruding periorbital fat)
• Chin augmentation (reshaping or enhancing the size of the chin)
• Chin/nose/cheek implants
• Face lift/forehead lift (e.g., rhytidectomy)
• Facial reconstruction for femininization or masculinization (e.g., facial bone reduction)
• Forehead augmentation
• Hair reconstruction (hair removal/hair transplantation)
• Jaw/mandibular reduction or augmentation
• Lipofilling
• Lip reduction/enhancement (decreasing/enlarging lip size)
• Rhinoplasty (reshaping of the nose) including nose implants
• Trachea shave (Adam’s apple shaving)/reduction thyroid chondroplasty (reduction of the thyroid cartilage)

Permanent Hair Removal:

Additional surgeries may be proposed (i.e., body feminization or masculinization) for an individual who is planning to undergo or has undergone gender reassignment surgery. Including, but not limited to, the following surgical procedures need to be reviewed for medical necessity (see documentation needed for medical necessity determination in the Policy Guidelines section):

• Electrolysis or laser hair removal for facial, or body areas other than pubic region. Reevaluation by a qualified medical provider is needed if treatment exceeds 6 months or 30 hours.
• Pubic area electrolysis or laser hair removal may be considered medically necessary when there is a recommendation from the surgeon (with documentation in the medical record) of the need to be done related to a planned genital reconstructive surgery. This treatment can be done during the same time period as hormonal therapy and living in the preferred gender role full time. Photographic and endocrinologist documentation is not required. Re-evaluation by a qualified medical provider is needed if treatment exceeds 6 months or 30 hours.

Voice Therapy and Surgery:

Additional surgeries may be proposed (i.e., body feminization or masculinization) for an individual who is planning to undergo or has undergone gender reassignment surgery. Including, but not limited to, the following surgical procedures need to be reviewed for medical necessity (see documentation needed for medical necessity determination in the Policy Guidelines section):

• Cricothyroid approximation (voice modification that raises the vocal pitch by stimulating contractions of the cricothyroid muscles with sutures)
• Laryngoplasty (reshaping of laryngeal framework)
• Voice modification surgery and voice retraining (speech therapy)