Policy: Gender-Affirming Facial Procedures Medical Necessity Criteria
Policy Number: UR 75
Last Update: 2020-09
Issued in: Washington, Oregon

This policy applies to Medicare

Facial Reconstruction:

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Gender-affirming facial procedures may be considered medically necessary when ALL of the following criteria are met:

1. With regard to the member:
   1. Member has persistent, well-documented gender dysphoria;
   2. Member is undergoing or has undergone other treatments to transition gender;
   3. Member has the capacity to make a fully informed decision and consent for treatment;
   4. Member is 18 years of age or older;
   5. Any significant medical or mental health concerns are well-controlled; AND
2. With regard to the requested procedure(s):
   1. Procedures for facial feminization may include (but are not limited to) mandible contouring, thyroid chondroplasty, rhinoplasty, and forehead reduction, among others. For each requested procedure, documentation that the member experiences dysphoria specifically associated with that facial element is required (e.g. documentation of dysphoria related to a stereotypically masculine nose for a requested rhinoplasty). Suitable documentation should be in the form of a mental health assessment produced by an experienced gender therapist who has evaluated the patient; AND
   2. The goal of each procedure is to alter or reshape the facial feature to an appearance that is within the range of normal for the member's identified gender, as determined by a board-certified Plastic Surgeon.

Procedures intended solely to reduce the appearance of aging and will not result in significant improvement of the condition being treated are considered not medically necessary.