Policy: Gender Reassignment/Gender Affirming Surgery and Treatments
Policy Number: 7.01.84
Last Update: 2021-01-20
Issued in: New York

Breast Reconstruction:

Based on our criteria and assessment of peer-reviewed literature, breast augmentation/implants, including nipple/areola reconstruction and tattooing, for transitioning individuals who were assigned male at birth, has been shown to be a beneficial and effective intervention for gender dysphoria, and, therefore, is considered medically appropriate when ALL of all the following criteria are met:

A. The patient has received a recommendation letter from a qualified mental health professional (refer to Policy Guidelines below); and

B. The patient has been diagnosed with persistent gender dysphoria, including all of the following:

1. The desire to live and be accepted as a member of the identified gender, usually accompanied by the wish to make their body as congruent as possible with the preferred gender through surgery and hormone treatment; and
2. The gender dysphoria has been present persistently for at least one year; and
3. The condition is not a symptom of another mental disorder or a chromosomal abnormality; and
4. The condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and

C. The patient has the capacity to make a fully informed decision and to consent to treatment, as well as the ability to comply with all aftercare instructions, including recommended medical, surgical, nursing, and/or psychological care recommended by the individual’s providers; and

D. The patient has reached the age of majority (18 years of age or older); and

E. If significant medical or mental health concerns are present, they must be reasonably well controlled; and

F. The patient has completed a minimum of 24 months of hormone therapy, unless hormone therapy is medically contraindicated, or the patient is otherwise unable to take hormones.

Facial Reconstruction:

Based upon our assessment of the peer-reviewed literature, other surgeries and procedures for the treatment of gender dysphoria, including, but not limited to, facial feminization or masculinization surgery (i.e., blepharoplasty, liposuction of the face or neck, rhinoplasty, facial bone reconstruction, jaw shortening/sculpturing, chin augmentation, cheek augmentation, tracheal shaving/thyroid chondroplasty, hair reconstruction as part of forehead feminization surgery, and electrolysis or laser hair removal of face and/or neck hair (refer to Policy Guideline IX)), liposuction, lipofilling, and gluteal augmentation, will be reviewed on a case-by-case basis by a Health Plan medical director with experience in treating patients with mental health conditions and may be considered medically appropriate when ALL of the following criteria are met:

A. The patient has received a recommendation letter from a qualified mental health professional (refer to Policy Guidelines below).

B. The patient has been diagnosed with persistent gender dysphoria, including all of the following:

1. The patient has a desire to live and be accepted as a member of their identified gender, usually accompanied by the wish to make their body as congruent as possible with the preferred gender through surgery and hormone treatment;
2. The gender dysphoria has been present persistently for at least one year;
3. The condition is not a symptom of another mental disorder or a chromosomal abnormality; and
4. The condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The patient has the capacity to make a fully informed decision and to consent to treatment, as well as the ability to comply with all aftercare instructions, including recommended medical, surgical, nursing, and/or psychological care recommended by the individual’s providers.

D. The patient has reached the age of majority (18 years of age or older).

E. If significant medical or mental health concerns are present, they are reasonably well controlled.

F. The patient has completed a minimum of 24 months of hormone therapy, unless hormone therapy is medically contraindicated, or the patient has a history of a severe medical or psychiatric adverse effect from hormonal treatments.

G. The treating physician has determined that the requested procedure is medically necessary to treat the patient’s gender dysphoria.

Voice Therapy and Surgery:

Based upon our assessment of the peer-reviewed literature, feminizing or masculinizing voice therapy and/or voice training services have been medically proven to be effective and, therefore, are considered medically appropriate for the treatment of gender dysphoria, when performed by a state-licensed speech-language pathologist or speech therapist. (Refer to Corporate Medical Policy # 8.01.13 Speech Pathology and Therapy).

Based upon our assessment of the peer-reviewed literature, voice modification surgery has been medically proven to be effective and, therefore, will be reviewed on a case-by-case basis by a Health Plan medical director with experience in treating patients with mental health conditions, and may be considered medically appropriate when ALL of the following criteria are met:

A. The patient has received a recommendation letter from a qualified mental health professional (refer to Policy Guidelines below).

B. The patient has been diagnosed with persistent gender dysphoria, including all of the following:

1. The patient has a desire to live and be accepted as a member of the identified gender, usually accompanied by the wish to make their body as congruent as possible with the preferred gender through surgery and hormone treatment;
2. The gender dysphoria has been present persistently for at least one year;
3. The condition is not a symptom of another mental disorder or a chromosomal abnormality; and
4. The condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The patient has the capacity to make a fully informed decision and to consent to treatment, as well as the ability to comply with all aftercare instructions, including recommended medical, surgical, nursing, and/or psychological care recommended by the individual’s providers.

D. The patient has reached the age of majority (18 years of age or older).

E. If significant medical or mental health concerns are present, they are reasonably well-controlled.

F. The patient has completed a minimum of 24 months of masculinizing hormone therapy prior to seeking voice masculinization surgery, unless hormone therapy is medically contraindicated, or the patient is otherwise unable to take hormones.

G. The patient has completed a trial of speech therapy and/or voice training services prior to seeking voice modification surgery.

H. The treatment plan includes post-operative voice training.

I. The treating physician has determined that the requested procedure is medically necessary to treat the patient’s gender dysphoria.

Youth Services:

Based upon our criteria and assessment of the peer-reviewed literature, hormone therapy (i.e., gonadotropin-releasing hormone agents/pubertal suppressants and cross-sex hormones), with the exception of histrelin acetate (See Policy Statement XI) has been shown to be a beneficial and effective intervention for gender dysphoria, and, therefore, is considered medically appropriate (refer to Policy Guideline I).

[For mastectomy] if under the age of majority, meets all of the following criteria for early intervention:

1. has consent from both parents/guardians for surgery when applicable;
2. has identified as transgender for at least two years;
3. has been living in the desired gender role for at least one year;
4. has been receiving testosterone treatment for at least one year;
5. has received an additional letter of referral from a second qualified mental health professional or physician (refer to Policy Guidelines below);
6. has compelling reasons impacting their physical and/or psychological well-being, as documented by the patient’s mental health/adolescent medicine provider(s); and
7. has reasonably good control over any significant medical or mental health concerns that are present.