Policy: Transgender Surgical Procedures
Last Update: 2021-06-16
Issued in: Massachusetts

This policy applies to Medicaid

Breast Reconstruction:

Tufts Health Plan may authorize the coverage of transgender surgery procedures listed in this guideline for Members who have this benefit included in their plan document when ALL of the following criteria are met:

1. The Member has a definitive diagnosis of persistent gender dysphoria that has been made and documented by a qualified licensed mental health professional such as a licensed psychiatrist, psychologist or other licensed physician experienced in the field
2. The Member has received continuous hormone therapy for 12 months or more under the supervision of a physician. Exceptions: The Member has a medical contraindication that is attested to by the treating endocrinologist; or when the request is mastectomy only for female to male surgery.
3. The Member has lived as their reassigned gender full-time for 12 months or more. (Numbers 2 and 3 may occur concurrently.)
4. The Member’s medical and mental health providers document that there are no contraindications to the planned surgery and agree with the plan (within three months of the Prior Authorization request).

When the above guidelines are met, Tufts Health Plan may authorize one or more of the following covered surgeries, up to the Member’s benefit limit: .. Mammaplasty (breast augmentation)

Facial Reconstruction:

Tufts Health Plan may authorize the coverage of transgender surgery procedures listed in this guideline for Members who have this benefit included in their plan document when ALL of the following criteria are met:

1. The Member has a definitive diagnosis of persistent gender dysphoria that has been made and documented by a qualified licensed mental health professional such as a licensed psychiatrist, psychologist or other licensed physician experienced in the field
2. The Member has received continuous hormone therapy for 12 months or more under the supervision of a physician. Exceptions: The Member has a medical contraindication that is attested to by the treating endocrinologist; or when the request is mastectomy only for female to male surgery.
3. The Member has lived as their reassigned gender full-time for 12 months or more. (Numbers 2 and 3 may occur concurrently.)
4. The Member’s medical and mental health providers document that there are no contraindications to the planned surgery and agree with the plan (within three months of the Prior Authorization request).

When the above guidelines are met, Tufts Health Plan may authorize one or more of the following covered surgeries, up to the Member’s benefit limit:

• Facial bone reduction
• Blepharoplasty
• Rhinoplasty
• Rhytidectomy
• Osteoplasty
• Genioplasty
• Forehead or cheek augmentation
• Mandible/jaw contouring
• Reduction thyroid chondroplasty

Youth Services:

No age requirement listed for surgery.