Policy: Gender Reassignment/Gender Affirming Surgery
Policy Number: 115
Last Update: 2021-06-07
Issued in: New Jersey

Body Contouring:

1. Non-genital, non-breast aesthetic surgical procedures are considered cosmetic in nature, even in the presence of a contract benefit for gender affirming surgery. These include, but may not be limited to, the following:
   
   1. Procedures that assist in feminization (male-to-female):
      
      1. reduction thyroid chondroplasty (trachea shave)
      2. suction-assisted lipoplasty of the waist
      3. rhinoplasty
      4. facial feminization surgery / facial bone reduction / jaw shortening / sculpturing
      5. face-lift
      6. blepharoplasty
      7. voice modification surgery (vocal cord shortening)
      8. hair reconstruction / hair removal / electrolysis
      9. rhytidectomy
      10. gluteal augmentation (implants/lipofilling)
   2. Procedures that assist in masculinization (female-to-male):
      
      1. voice modification surgery to obtain a deeper voice (rarely done per WPATH Standards of Care )
      2. liposuction (e.g., reduce fat in hips, thighs, and buttocks)
      3. pectoral implants
      4. chin implants
      5. lip reduction

Breast Reconstruction:

1. Criteria for mastectomy and creation of a male chest in female-to-male members:
   
   1. Single letter of referral from a qualified mental health professional (see Policy Guidelines II, III), and
   2. Persistent, well-documented gender dysphoria (see Policy Guidelines I); and
   3. Capacity to make a fully informed decision and to give consent for treatment; and
   4. Age of majority (18 years of age or older) - For members younger than 18 years of age, please see NOTE below; and
   5. If significant medical or mental health concerns are present, they must be reasonably well controlled.
      (NOTE: Hormone therapy is not a prerequisite.
      According to the WPATH Standards of Care 7th Edition, ”Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression.”)
2. Criteria for breast augmentation (implants/lipofilling) in male-to-female members:
   
   1. Single letter of referral from a qualified mental health professional (see Policy Guidelines II, III), and
   2. Persistent, well-documented gender dysphoria (see Policy Guidelines I); and
   3. Capacity to make a fully informed decision and to give consent for treatment; and
   4. Age of majority (18 years of age or older); and
   5. If significant medical or mental health concerns are present, they must be reasonably well controlled.
      (NOTE: Although not an explicit criterion, WPATH Standards of Care (Revision 7 p. 65) recommended that male-to-female members undergo feminizing hormone therapy (minimum of 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical/aesthetic results.)

Youth Services:

For mastectomy:

For members younger than 18 years of age, please see NOTE below;

(NOTE: Hormone therapy is not a pre-requisite.

According to the WPATH Standards of Care 7th Edition, "Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression.")