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:
- Abdominoplasty, blepharoplasty, neck tightening or removal of redundant skin
- Breast, brow, face or forehead lifts
- Calf, cheek, chin, nose or pectoral implants Collagen injections
- Drugs to promote hair growth or loss
- Electrolysis (unless required for vaginoplasty or phalloplasty)
- Facial bone reconstruction, reduction or sculpturing (including jaw shortening) and rhinoplasty
- Hair transplantation
- Lip reduction
- Liposuction
- 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.
Updated on Nov 6, 2020