Policy: Gender Reassignment Surgery
Last Update: 2021-04-01
Next Update: 2022-03
Issued in: New York

Breast Reconstruction:

BREAST/CHEST SURGERY

In addition to the criteria 1-3 and 5 above, the following criterion must also be met for individuals undergoing breast/chest surgeries:

8. One referral from a qualified mental health professional who has independently assessed the individual is documented. Gender affirmation surgery is considered not medically necessary when one or more of the criteria above have not been met. Medically necessary male to female sex affirmation surgical procedures include the following:

• Orchiectomy • Penectomy • Vaginoplasty • Clitoroplasty • Labiaplasty Medically necessary female to male sex affirmation surgical procedures include the following: • Hysterectomy • Salpingo-oophorectomy • Vaginectomy/colpectomy • Initial mastectomy/breast reduction • Nipple reconstruction, including tattooing, following a mastectomy • Urethroplasty • Metoidioplasty • Phalloplasty • Scrotoplasty

Notes:

Generally speaking, the following services are not covered, and considered cosmetic, unless determined medically necessary to treat the member’s condition, based on scientific, medical literature and Medical Director review (this is not an all-inclusive list):

• Liposuction/body contouring/lipofilling • Rhinoplasty • Facial bone reconstruction for feminization or masculinization • Facial feminization surgery • Jaw/mandibular reduction/augmentation/sculpturing • Chin augmentation/reshaping • Cheek, chin and nose implants • Tracheal shaving/reduction thyroid chondroplasty/thyroid cartilage reduction • Face lift (e.g., face, brow, etc.) • Blepharoplasty/brow reduction/brow lift • Voice modification surgery • Hair removal or electrolysis/hairplasty • Hair augmentation/reconstruction • Breast augmentation/implants • Skin resurfacing • Lip reduction/enhancement • Procedures (prior to gender affirmation surgery) aimed at preserving fertility (e.g., procurement, cryopreservation, storage) • Abdominoplasty • Implants for body contouring (e.g., calf) • Pectoral Implants • Collagen injections • Gluteal augmentation • Vulvoplasty