Policy: Gender Affirmation Services /Gender Dysphoria
Policy Number: 7.01.123
Last Update: 2020-11-01
Issued in: Maryland

Body Contouring:

Other surgeries for assisting in body feminization or body masculinization are generally labeled cosmetic as they provide no significant improvement in physiologic function. However, these surgeries can be considered medically necessary depending on the unique clinical situation of a given patient’s condition. These surgeries include but are not limited to: ...

• Gluteal augmentation via implants and lipofilling
• Liposuction/Lipoplasty: removal of fat and/or contour modeling
• Lipofilling
• Pectoral implants

Breast Reconstruction:

1. The individual is age 18 years or older; and
2. The individual has a confirmed diagnosis of gender dysphoria including all the following: ...
3. For those without a medical contraindication to hormonal therapy, the individual has undergone a minimum of 12 continuous months of hormonal therapy that was recommended by a mental health professional and supervised by a physician over the entire 12-month period; and
4. Documentation that the individual has completed a minimum of 12 months of successful continuous full-time, real-life experience in their desired gender, across a wide span of life experiences and events that may occur throughout the year (i.e., holidays, vacations, season-specific school and/or work experience, family events) ...
5. The individual has received the following referrals for surgery: One letter of referral from a licensed mental health professional, if the individual is seeking breast/chest surgery (e.g., mastectomy, chest reconstruction, or augmentation mammoplasty)

The gender reassignment surgeries that may be performed for transwomen (male to female) that meet the above 5 criteria include but are not limited to: ... Mammoplasty: breast augmentation

Facial Reconstruction:

Other surgeries for assisting in body feminization or body masculinization are generally labeled cosmetic as they provide no significant improvement in physiologic function. However, these surgeries can be considered medically necessary depending on the unique clinical situation of a given patient’s condition. These surgeries include but are not limited to:

• Rhinoplasty: reshaping of the nose
• Rhytidectomy: face lift
• Blepharoplasty: removal of redundant skin of the upper and/or lower eyelids and protruding periorbital fat
• Hair removal via electrolysis, laser, and waxing/Hair transplantation
• Facial bone reduction: facial feminization
• Chin augmentation reshaping or enhancing the size of the chin
• Lip reduction/enhancement: decreasing/enlarging lip size
• Trachea shave/reduction thyroid chondroplasty: reduction of the thyroid cartilage
• Genioplasty

Permanent Hair Removal:

Other surgeries for assisting in body feminization or body masculinization are generally labeled cosmetic as they provide no significant improvement in physiologic function. However, these surgeries can be considered medically necessary depending on the unique clinical situation of a given patient’s condition. These surgeries include but are not limited to: ...

• Hair removal via electrolysis, laser, and waxing/Hair transplantation

Voice Therapy and Surgery:

Other surgeries for assisting in body feminization or body masculinization are generally labeled cosmetic as they provide no significant improvement in physiologic function. However, these surgeries can be considered medically necessary depending on the unique clinical situation of a given patient’s condition. These surgeries include but are not limited to: ...

• Laryngoplasty: reshaping of laryngeal framework (voice modification surgery)
• Voice modification surgery/Cricothyroid approximation: voice modification that raises the vocal pitch by stimulating contractions of the cricothyroid muscle with sutures

Youth Services:

Hormone therapy for individuals under the age of 18:

• For those without a medical contraindication to hormonal therapy, authorization of 12 months of hormone therapy is considered medically necessary for young adolescents with a diagnosis of gender dysphoria who are prescribed hormone therapy when ALL of the following criteria are met:
• Hormone therapy is prescribed for pubertal suppression for the treatment of gender dysphoria; and
• The individual has reached at least Tanner stage 2 of puberty.

Authorization of for continuation therapy must meet ALL initial authorization criteria.

Refer to CVS Caremark Specialty Guideline Management: Lupron Depot-PED and WPATH criteria Section VI.