Policy: Gender Confirming Surgery
Last Update: 2020-10-01

Breast Reconstruction:

Breast/chest surgery for Male-to-Female (MtF) members is medically appropriate with ALL of the following: (Hormone therapy is not a prerequisite)

a. One referral from qualified behavioral/mental health professional (See Appendix B for referral letter requirements)

b. Persistent, well-documented gender dysphoria

c. Age of majority (18 years of age or older)

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

Facial Reconstruction:

Gender confirming facial procedures are considered medically appropriate when ALL the following are met:

1. Two referrals from licensed behavioral/mental health professionals (see Attachment A)
2. Persistent, well-documented gender dysphoria
3. Capacity to make a fully informed decision and to consent for treatment
4. Age of majority (18 years of age or older)
5. If significant medical or mental health concerns are present, they must be well controlled
6. 12 months of continuous hormone therapy as appropriate to the member’s gender goals (unless hormones are not clinically indicated for the individual).
7. 12 continuous months of living in a gender role that is congruent with the member’s identity

The list of gender confirming procedures that would be considered are:

• Tracheal Shave
• Facial hair removal
• Rhinoplasty/Septoplasty
• Jaw Contouring
• Chin Contouring
• Forehead Contouring
• Browlift/Ptosis Repair
• Cheek/Chin Implants
• Blepharoplasty
• Hairline Advancement/Correction

Permanent Hair Removal:

The following adjunct procedures are considered medically necessary if the specific criteria is met for the procedure requested: Hair removal for surgical reconstruction (i.e. genital hair removal) that meets ALL of the following criteria:

1. Hair removal for surgical reconstruction (i.e. genital hair removal) that meets ALL of the following criteria:
   1. Requested hair removal is prior to male to female genital surgery involving hair-bearing flabs associated with vaginoplasty due to 1 or more of the following:
      1. Skin area will be brought into contact with urine (used to construct a neourethra)
      2. Skin area to be moved to reside within a partially closed cavity within the body (e.g. used to line the neovagina)
2. Request is NOT for hair-bearing skin that remains outside of the body after gender reassignment surgery as that does not need to be removed and will NOT be covered
3. Hair removal will involve 1 or more of the following modalities which may take up to a year prior to surgery:
   1. Electrolysis
   2. Laser hair removal
4. Request is NOT for hair removal for cosmetic reasons as that is NOT a covered benefit
5. Patient meets criteria for genital surgery in section F or gender confirming facial procedures in section G.

Voice Therapy and Surgery:

The following adjunct procedures are considered medically necessary if the specific criteria is met for the procedure requested: ... Voice therapy/voice modification.

Youth Services:

Reversible therapy with puberty-suppressing hormones are medically appropriate with ALL of the following:

1. The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed)
2. Gender dysphoria emerged or worsened with the onset of puberty
3. The member has experienced the onset of puberty to at least Tanner Stage 2.
4. Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g. may compromise adherence with treatment) have been addressed such that the adolescent’s situation and functioning are stable enough to start treatment
5. The adolescent has given informed consent, and particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.

Chest surgery in FtM adolescent patients may be carried out prior to 18 with ALL of the following:

1. Meets all of the criteria for treatment of adolescent with puberty-suppressing hormones and masculinizing hormones
2. Reached the age of medical consent
3. Had ample time (preferably one year) living in the desired gender role
4. Undergone one year of testosterone treatment.