Policy: Gender Affirming/Reassignment Surgery (Commercial)
Policy Number: MG.MM.SU.28m
Last Update: 2021-05-07
Issued in: Connecticut

Body Contouring:

Coverage is not available for any surgeries, services or procedures that are purely cosmetic (i.e., when performed solely to enhance appearance, but not to medically treat the underlying gender dysphoria). 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. Gluteal augmentation

6. Electrolysis (unless required for vaginoplasty or phalloplasty)

7. Facial bone reconstruction, reduction, or sculpturing (including jaw shortening) and rhinoplasty

8. Hair transplantation

9. Lip reduction

10. Liposuction

11. Thyroid chondroplasty

12. Voice therapy, voice lessons or voice modification surgery

Youth Services:

Treatment with cross-sex hormones, including testosterone, cypionate, conjugated estrogen, and estradiol, for members greater than or equal to 16 years of age, when based upon a determination of medical necessity made by a qualified medical professional. (Members less than 18 years of age must meet Criteria # 1).

Note: Requests for coverage of cross-sex hormones for members less than 16 years of age will be reviewed on a case-by- case basis