Policy: Transgender Health Services
Policy Number: Stride (HMO) Medicare Advantage
Last Update: 2020-06-12
Issued in: Massachusetts

This policy applies to Medicare

Breast Reconstruction:

Harvard Pilgrim Health Care (HPHC) considers transgender surgical services as medically necessary when documentation and letters confirm ALL of the following for transgender breast/chest surgery:

1. Member age 18 years or older has been diagnosed, by an appropriately trained Mental Health Professional (MHP), with gender dysphoria/gender incongruence; AND
2. Transgender surgery has been recommended by ONE treating clinicians
3. Capacity to make fully informed decisions and to consent for treatment
4. If significant medical or mental health concerns are present, they must be reasonably well controlled

Transfeminine surgeries covered include:

• Augmentation mammoplasty

Facial Reconstruction:

Harvard Pilgrim Health Care (HPHC) considers transgender surgical services as medically necessary when documentation and confirm ALL the following for transgender genital surgery:

1. Member age 18 years or older has been diagnosed, by an appropriately trained Mental Health Professional (MHP), with gender dysphoria/gender incongruence; AND
2. Transgender surgery has been recommended by TWO treating clinicians
3. Capacity to make fully informed decision and to consent for treatment
4. If significant medical or mental health concerns are present, they must be well controlled
5. Complete 12 continuous months of hormone therapy appropriate to the member’s the desired gender (unless medically contraindicated)

Transfeminine surgeries covered include:

• Tracheoplasty
• Blepharoplasty (lower and upper eyelid)
• Blepharoptosis
• Brow Ptosis
• Rhytidectomy
• Suction assisted lipectomy
• Genioplasty
• Osteoplasty
• Otoplasty
• Rhinoplasty
• Forehead contouring
• Mandible/jaw contouring

Fertility Preservation:

HPHC also covers retrieval, cryopreservation, and storage (up to one year) of sperm or eggs when documentation confirms an eligible member with gender dysphoria/gender incongruence will be undergoing gender reassignment treatment that is likely to result in infertility.