Policy: Gender Affirming/Reassignment Surgery (Commercial)
Policy Number: MG.MM.SU.28m
Last Update: 2020-05-08
Issued in: Connecticut

Body Contouring:

The following surgery, services and procedures will be reviewed on a case by case basis.

It is expected that the clinical rationale for each requested procedure is specifically documented in the letter of medical necessity from the treating physician:

• Calf, cheek, chin, nose or pectoral implants Collagen injections
• Liposuction

Breast Reconstruction:

Breast augmentation is considered medically necessary provided that the member has completed a minimum of 24 months of hormone therapy, during which time breast growth has been negligible; or hormone therapy is medically contraindicated; or the member is otherwise unable to take hormones.

Facial Reconstruction:

The following surgery, services and procedures will be reviewed on a case by case basis.

It is expected that the clinical rationale for each requested procedure is specifically documented in the letter of medical necessity from the treating physician:

1. Abdominoplasty, blepharoplasty, neck tightening or removal of redundant skin
2. Breast, brow, face or forehead lifts
3. Calf, cheek, chin, nose or pectoral implants Collagen injections
4. Drugs to promote hair growth or loss
5. Electrolysis (unless required for vaginoplasty or phalloplasty)
6. Facial bone reconstruction, reduction or sculpturing (including jaw shortening) and rhinoplasty
7. Hair transplantation
8. Lip reduction
9. Liposuction
10. Thyroid chondroplasty

Permanent Hair Removal:

Genital electrolysis is not considered a surgical procedure, but is performed in conjunction with genital surgery (i.e., when required for vaginoplasty or phalloplasty)

The following surgery, services and procedures will be reviewed on a case by case basis.

It is expected that the clinical rationale for each requested procedure is specifically documented in the letter of medical necessity from the treating physician:

• Electrolysis (unless required for vaginoplasty or phalloplasty)

Voice Therapy and Surgery:

The following surgery, services and procedures will be reviewed on a case by case basis.

It is expected that the clinical rationale for each requested procedure is specifically documented in the letter of medical necessity from the treating physician:

• Voice therapy, voice lessons or voice modification surgery

Youth Services:

Requests for gender reassignment surgery for members less than 18 years will be reviewed on a case-by-case basis.