Policy Issued By: Blue Cross Blue Shield of New Mexico

Policy Title: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Body Contouring:

Procedures or services to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment services treatment plan may be considered medically necessary for the treatment of gender dysphoria ONLY. These procedures may include the following:

• Abdominoplasty;
• Calf implants;
• Liposuction/lipofilling or body contouring or modeling of waist, buttocks, hips, and thighs reduction;
• Pectoral implants;
• Redundant/excessive skin removal;

Policy Issued By: Blue Cross Blue Shield of Texas

Policy Title: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Body Contouring:

F. Secondary Sexual Characteristic (Masculinizing or Feminizing) Gender Reassignment Surgeries and Related Services:

Procedures or services to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment services treatment plan may be considered medically necessary for the treatment of gender dysphoria ONLY. These procedures may include the following:

• Liposuction/lipofilling or body contouring or modeling of waist, buttocks, hips, and thighs reduction;

Policy Issued By: BlueCross BlueShield of Western New York

Policy Title: Gender Affirming Surgery

Body Contouring:

Cosmetic and Not Medically Necessary:

The following procedures, when requested alone or in combination with other procedures, are considered cosmetic and not medically necessary when applicable reconstructive criteria above have not been met, or when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender affirming surgery, including, but not limited to, the following:

1. Abdominoplasty
2. Bilateral mastectomy
3. Blepharoplasty
4. Breast augmentation
5. Brow lift
6. Calf implants
7. Face lift
8. Facial bone reconstruction
9. Facial implants
10. Gluteal augmentation
11. Hair removal (for example, electrolysis or laser) and hairplasty, when the criteria above have not been met
12. Jaw reduction (jaw contouring)
13. Lip reduction/enhancement
14. Lipofilling/collagen injections
15. Liposuction
16. Nose implants
17. Pectoral implants
18. Rhinoplasty
19. Thyroid cartilage reduction (chondroplasty)
20. Voice modification surgery

Policy Issued By: Horizon Blue Cross Blue Shield of New Jersey

Policy Title: Gender Reassignment/Gender Affirming Surgery

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

Policy Issued By: Independence Blue Cross

Policy Title: Treatment of Gender Dysphoria

Body Contouring:

POTENTIALLY COSMETIC

The following procedures are considered potentially cosmetic services, unless medical necessity demonstrating a functional impairment can be identified. Services that are cosmetic are a benefit contract exclusion for all products of the Company, and therefore, not eligible for reimbursement consideration. This is not an all-inclusive list, refer to any applicable medical policies.

• Abdominoplasty
• Blepharoplasty
• Body contouring procedures (e.g., liposuction, lipectomy)
• Botox injections
• Calf implantation
• Cervicoplasty/platysmaplasty
• Chin augmentation (genioplasty, mentoplasty)
• Collagen injections
• Dermabrasions/chemical peels
• Excision of redundant skin
• Facial masculinizing/feminizing surgeries (e.g., facial bone reduction)
• Facial prosthesis (e.g. nasal, orbital)
• Forehead reduction
• Gluteal augmentation (e.g., silicone implants, fat transfer, fat grafting)
• Hair reconstruction (e.g. hair removal/electrolysis, hair transplantation, wigs)
• Injectable dermal fillers (e.g., Sculptra, Radiesse)
• Lip reduction/enhancement
• Orthognathic procedures
• Otoplasty
• Pectoral implantation
• Rhinoplasty
• Rhytidectomy
• Tattooing (non therapeutic)
• Trachea shave/reduction thyroid chondroplasty
• Voice therapy, voice modification, laryngoplasty, cricothyroid approximation

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.