Policy: Gender Affirming Procedures
Policy Number: HNCA.CP.MP.496
Last Update: 2021-05
Issued in: California
This policy applies to Medicaid
Body Contouring:
Medically Necessary/Reconstructive Surgery
It is the policy of Health Net of California that each of the following procedures, when used specifically to improve the appearance of an individual undergoing gender reassignment surgery or actively participating in a documented gender reassignment surgery treatment plan, must be evaluated to determine if it is medically necessary reconstructive surgery to create a normal appearance for the gender with which the member identifies. Prior to making a clinical determination of coverage, it may be necessary to consult with a qualified and licensed mental health professional and the treating surgeon.
- Abdominoplasty
- Liposuction
The above section clarifies how the plan administers benefits in accordance with the WPATH, SOC, Version 7. Provided a patient has been properly diagnosed with gender dysphoria or GID by a mental health professional or other provider type with appropriate training in behavioral health and competencies to conduct an assessment of gender dysphoria or GID, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy, certain options for social support and changes in gender expression are considered to help alleviate gender dysphoria or GID.
Breast Reconstruction:
A. Age > 18
a. Exception: in adolescent female to male patients < 18 years, chest surgery may be considered after one year of testosterone treatment;
B. Persistent, well-documented gender dysphoria with evidence the member has lived at least 12 continuous months in a gender role that is congruent with their gender identity (not required for mastectomy in female to male except for those < 18 years);
C. Capacity to make a fully informed decision and to consent for treatment;
D. If significant medical or mental health concerns are present, they must be reasonably well controlled;
E. Written referral letter(s) from a qualified mental health practitioner (See below for qualifications) based on the type of surgery (one referral for chest surgery; two referrals for genital surgery) and containing the following:
1. The client’s general identifying characteristics;
2. Results of the client’s psychosocial assessment, including any diagnoses;
3. The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;
4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery;
5. A statement about the fact that informed consent has been obtained from the patient;
6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.
7. The degree to which the member has followed the standards of care to date and the likelihood of future compliance
8. For providers working within a multidisciplinary specialty team, a letter may not be necessary, rather, the assessment and recommendation can be documented in the patient’s chart.
Note: Although not an explicit criterion, it is recommended that male to female individuals undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.
It is the policy of Health Net of California that each of the following procedures, when used specifically to improve the appearance of an individual undergoing gender reassignment surgery or actively participating in a documented gender reassignment surgery treatment plan, must be evaluated to determine if it is medically necessary reconstructive surgery to create a normal appearance for the gender with which the member identifies. Prior to making a clinical determination of coverage, it may be necessary to consult with a qualified and licensed mental health professional and the treating surgeon. ... Breast augmentation
Facial Reconstruction:
Medically Necessary/Reconstructive Surgery
It is the policy of Health Net of California that each of the following procedures, when used specifically to improve the appearance of an individual undergoing gender reassignment surgery or actively participating in a documented gender reassignment surgery treatment plan, must be evaluated to determine if it is medically necessary reconstructive surgery to create a normal appearance for the gender with which the member identifies. Prior to making a clinical determination of coverage, it may be necessary to consult with a qualified and licensed mental health professional and the treating surgeon.
- Blepharoplasty
- Facial feminization
- Facial bone reduction
- Hair transplantation
- Hair removal
- Reduction thyroid chondroplasty
- Rhinoplasty
The above section clarifies how the plan administers benefits in accordance with the WPATH, SOC, Version 7. Provided a patient has been properly diagnosed with gender dysphoria or GID by a mental health professional or other provider type with appropriate training in behavioral health and competencies to conduct an assessment of gender dysphoria or GID, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy, certain options for social support and changes in gender expression are considered to help alleviate gender dysphoria or GID.
Permanent Hair Removal:
Medically Necessary/Reconstructive Surgery
It is the policy of Health Net of California that each of the following procedures, when used specifically to improve the appearance of an individual undergoing gender reassignment surgery or actively participating in a documented gender reassignment surgery treatment plan, must be evaluated to determine if it is medically necessary reconstructive surgery to create a normal appearance for the gender with which the member identifies. Prior to making a clinical determination of coverage, it may be necessary to consult with a qualified and licensed mental health professional and the treating surgeon.
- Electrolysis*
- Hair transplantation
- Hair removal
The above section clarifies how the plan administers benefits in accordance with the WPATH, SOC, Version 7. Provided a patient has been properly diagnosed with gender dysphoria or GID by a mental health professional or other provider type with appropriate training in behavioral health and competencies to conduct an assessment of gender dysphoria or GID, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy, certain options for social support and changes in gender expression are considered to help alleviate gender dysphoria or GID.
For example, with respect to hair removal through electrolysis, laser treatment, or waxing, the WPATH “Statement of Medical Necessity for Electrolysis” (July 15, 2016) clarifies that patients with the same condition do not always respond to, or thrive, following the application of identical treatments. Treatment must be individualized, such as with electrolysis, and medical necessity should be determined according to the judgment of a qualified mental health professional and the referring physician.
The documentation to support the medical necessity for hair removal should include all three essential elements:
- A properly trained (in behavioral health) and competent (in assessment of gender dysphoria) professional has diagnosed the member with gender dysphoria or GID.
- The individual has completed 3 years of feminizing hormonal therapy.
- The medical necessity for electrolysis has been determined according to the judgment of a qualified mental health professional and the referring physician.
If any element remains to be satisfied before medical necessity can be determined, the individual should be directed to an appropriate network participating provider for consultation or treatment.
Voice Therapy and Surgery:
It is the policy of Health Net of California to consider voice modification surgery (such as laryngoplasty or shortening of the vocal cords) related to transgender dysphoria, consistent with World Professional Association for Transgender Health (WPATH) version 7 guidelines, according to the following:
A. Voice deepening surgery (eg thyroplasty) is considered medically necessary if the voice fails to deepen after 2 years of consistent masculinization hormone therapy.
B. Voice feminization surgery (cricothyroid approximation or CTA) is considered medically necessary when the following are met:
- Documentation demonstrating the member has been diagnosed with transgenderism (as defined by WPATH) by qualified professionals;
- Documentation that voice therapy has been provided and proven ineffective as attested to by a qualified voice therapist (trans-sensitive speech-language therapists using standard voice and communication protocols);
- Documentation of completed pre-operative assessments by both a laryngologist and speech-language therapist who agreed to the clinical benefits in achieving transitional goals;
- Documentation that a qualified voice and communication specialist (who is licensed and/or credentialed by the board responsible for speech therapists/speech-language pathologists) will follow the patient post-operatively to maximize the surgical outcome.
Youth Services:
Exception: in adolescent female to male patients < 18 years, chest surgery may be considered after one year of testosterone treatment
Updated on Nov 29, 2021