Policy: GENDER AFFIRMING SURGERY (FORMERLY REASSIGNMENT SURGERY FOR GENDER DYSPHORIA)
Policy Number: MP-1.144
Last Update: 2021-11-01
Issued in: Pennsylvania

Breast Reconstruction:

The individual participates in trans-gender counseling and meets all of the following:

When ALL of the above criteria are met for gender reassignment surgery, the following genital surgeries may be considered medically necessary for transwomen (male to female):

• failure of breast growth stimulation by estrogen (progression only to a young adolescent stage of development), or
• emergence of serious or intolerable adverse effects during estrogen administration, or
• medical contraindication to use of estrogen, or
• risk-benefit analysis determined that surgery is preferable to estrogen therapy.

Youth Services:

Individual consideration may be given to those under 18 years old wishing to undergo female to male chest surgery (see additional information in section below‡)

‡ Note: Per WPATH, chest surgery in Female to Male patients could be carried out prior to reaching the legal age of majority, after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery.

Notes:

Non-Covered Services: The following procedures are typically considered cosmetic services and not medically necessary to align with one’s gender, but may be considered medically necessary, in unique or acute cases (this list may not be all-inclusive): 

• Abdominoplasty 
• Blepharoplasty 
• Blepharoptosis 
• Breast augmentation for purposes not meeting the above criteria 
• Breast reduction, implant, revision/reconstruction for purposes not meeting the above criteria 
• Brow lift 
• Calf augmentation/implants 
• Cheek/malar implants  Chin augmentation  Collagen injections  Cricothyroid approximation  Dermabrasion/Skin resurfacing 
• Facial feminizing/sculpturing (e.g., jaw shortening, forehead reduction) 
• Forehead lift 
• Gamete preservation in anticipation of future infertility 
• Hair removal – Electrolysis or laser hair removal* 
• Hair transplantation 
• Laryngoplasty 
• Lip reduction/enhancement 
• Liposuction 
• Mastopexy 
• Nose implants 
• Removal of redundant skin
• Rhinoplasty 
• Rhytidectomy 
• Scrotoplasty 
• Trachea shave/reduction
• thyroid chondroplasty 
• Voice modification surgery 
• Voice therapy/voice lessons