Policy: Gender Affirming Interventions for Gender Dysphoria: Clinical Criteria and Policy
Policy Number: 54-0006
Last Update: 2021-04-01
Issued in: Washington

Body Contouring:

C. Other than gender reassignment surgeries listed in this policy, surgery and/or additional treatments to change specific appearance characteristics are considered not medically necessary as treatments of gender dysphoria, including, but not limited to the following:

1. Brow lifts;
2. Calf implants;
3. Cheek/malar implants;
4. Chin/nose implants;
5. Chondrolaryngoplasty;
6. Collagen injections;
7. Drugs for hair loss or growth;
8. Facial or trunk hair removal via laser or electrolysis;
9. Facial feminization;
10. Face lift;
11. Forehead lift;
12. Hair transplantation;
13. Jaw shortening;
14. Lip reduction;
15. Liposuction;
16. Mastopexy;
17. Neck tightening;
18. Pectoral implants;
19. Reduction thyroid chondroplasty;
20. Removal of redundant skin;
21. Suction-assisted lipoplasty of the waist;
22. Trachea shave;
23. Voice modification surgery; and
24. Voice therapy/lessons.

Youth Services:

For patients younger than 18 years of age, mastectomy may be considered a medically necessary surgical procedures. Other requirements outlined in this section must be met to proceed with mastectomy in those younger than 18 years of age.