Policy: Treatment of Gender Dysphoria
Policy Number: 0266
Last Update: 2021-05-18

Breast Reconstruction:

The procedures listed below are considered medically necessary under standard benefit plan language when the above listed criteria for gender reassignment surgery have been met, unless specifically excluded in the benefit plan language: ... Initial breast reconstruction including augmentation with implants

Facial Reconstruction:

The procedures listed below are considered not medically necessary under standard benefit plan language. However, some benefit plans may expressly cover some or all of the procedures listed below for gender reassignment surgery.

Note: For New York regulated benefit plans (e.g., insured):The procedures listed below will be further reviewed on a case-by-case basis by a medical director with particular consideration given to whether the proposed procedure(s) advance an individual’s ability to properly present and function in the identified gender role.

• Blepharoplasty
• Brow lift
• Cheek/malar implants
• Chin/nose implants, chin recontouring
• Collagen injections
• Face lift
• Forehead reduction and contouring
• Facial bone reduction (osteoplasty)
• Hair removal/hair transplantation
• Jaw reduction, contouring, augmentation
• Laryngoplasty
• Lip lift and lip filling
• Rhinoplasty
• Skin resurfacing (e.g., dermabrasion, chemical peels)
• Thyroid reduction chondroplasty
• Neck tightening

Permanent Hair Removal:

The procedures listed below are considered not medically necessary under standard benefit plan language. However, some benefit plans may expressly cover some or all of the procedures listed below for gender reassignment surgery.

Note: For New York regulated benefit plans (e.g., insured):The procedures listed below will be further reviewed on a case-by-case basis by a medical director with particular consideration given to whether the proposed procedure(s) advance an individual’s ability to properly present and function in the identified gender role. ... Electrolysis

Voice Therapy and Surgery:

The procedures listed below are considered not medically necessary under standard benefit plan language. However, some benefit plans may expressly cover some or all of the procedures listed below for gender reassignment surgery.

Note: For New York regulated benefit plans (e.g., insured):The procedures listed below will be further reviewed on a case-by-case basis by a medical director with particular consideration given to whether the proposed procedure(s) advance an individual’s ability to properly present and function in the identified gender role.

• Voice therapy/voice lessons
• Voice modification surgery

Youth Services:

Medically necessary treatment for an individual with gender dysphoria may include ANY of the following services, when services are available in the benefit plan: ... Hormonal therapy, including but not limited to androgens, anti-androgens, GnRH analogues*, estrogens, and progestins (Prior authorization requirements may apply). *Note: If use in adolescents, individual should have reached Tanner stage 2 of puberty prior to receiving GnRH agonist therapy.