These are a list of clinical criteria that have explicit coverage for body contouring.
Policy Issued By: Blue Cross Blue Shield of Minnesota
Policy Title: Gender Affirming Procedures for Gender Dysphoria
Body Contouring:
The following procedures and criteria for coverage are addressed in separate medical policies:
- Panniculectomy/Abdominoplasty
- Liposuction
Policy Issued By: Blue Cross Blue Shield of Montana
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 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:
- Abdominoplasty
- Bilateral mastectomy
- Blepharoplasty
- Breast augmentation
- Brow lift
- Calf implants
- Face lift
- Facial bone reconstruction
- Facial implants
- Gluteal augmentation
- Hair removal (for example, electrolysis or laser) and hairplasty, when the criteria above have not been met
- Jaw reduction (jaw contouring)
- Lip reduction/enhancement
- Lipofilling/collagen injections
- Liposuction
- Nose implants
- Pectoral implants
- Rhinoplasty
- Thyroid cartilage reduction (chondroplasty)
- Voice modification surgery
Policy Issued By: California
Policy Title: Gender Reassignment Surgery
Body Contouring:
Additional surgeries may be proposed (i.e., body feminization or masculinization) for an individual who is planning to undergo or has undergone gender reassignment surgery. Including, but not limited to, the following surgical procedures need to be reviewed for medical necessity (see documentation needed for medical necessity determination in the Policy Guidelines section):
- Calf implants
- Gluteal and hip augmentation (implants/lipofilling)
- Liposuction (removal of fat in the hips, thighs, or buttocks)
- Pectoral implants
- Suction-assisted lipoplasty of the waist
Policy Issued By: Health Net
Policy Title: Gender Affirming Procedures
Body Contouring:
Medically Necessary/Reconstructive Surgery
It is the policy of Health Net of California that each of the following procedures, when used specifically to improve the appearance of an individual undergoing gender reassignment surgery or actively participating in a documented gender reassignment surgery treatment plan, must be evaluated to determine if it is medically necessary reconstructive surgery to create a normal appearance for the gender with which the member identifies. Prior to making a clinical determination of coverage, it may be necessary to consult with a qualified and licensed mental health professional and the treating surgeon.
- Abdominoplasty
- Liposuction
The above section clarifies how the plan administers benefits in accordance with the WPATH, SOC, Version 7. Provided a patient has been properly diagnosed with gender dysphoria or GID by a mental health professional or other provider type with appropriate training in behavioral health and competencies to conduct an assessment of gender dysphoria or GID, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy, certain options for social support and changes in gender expression are considered to help alleviate gender dysphoria or GID.
Policy Issued By: Horizon Blue Cross Blue Shield of New Jersey
Policy Title: Gender Reassignment/Gender Affirming Surgery
Body Contouring:
- 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:
- Procedures that assist in feminization (male-to-female):
- reduction thyroid chondroplasty (trachea shave)
- suction-assisted lipoplasty of the waist
- rhinoplasty
- facial feminization surgery / facial bone reduction / jaw shortening / sculpturing
- face-lift
- blepharoplasty
- voice modification surgery (vocal cord shortening)
- hair reconstruction / hair removal / electrolysis
- rhytidectomy
- gluteal augmentation (implants/lipofilling)
- Procedures that assist in masculinization (female-to-male):
- voice modification surgery to obtain a deeper voice (rarely done per WPATH Standards of Care )
- liposuction (e.g., reduce fat in hips, thighs, and buttocks)
- pectoral implants
- chin implants
- 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.
Policy Issued By: Medi-Cal
Policy Title: Transgender Services
Body Contouring:
Nationally recognized medical experts in the field of transgender health care have identified the following core services in treating gender dysphoria:
- Mental and behavioral health services
- Hormone therapy
- A variety of surgical procedures that bring primary and secondary gender characteristics into conformity with the individual’s identified gender
Medically necessary covered services are those services that “are reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis and treatment of disease, illness or injury” (California Code of Regulations [CCR], Title 22, Section 51303). Medical necessity is assessed and services shall be recommended by treating licensed mental health professionals and physicians and surgeons experienced in treating patients with gender dysphoria.
In the case of transgender services, “normal appearance” is determined by referencing the gender with which the recipient identifies. Reconstructive surgery to create a normal appearance for transgender recipients is determined to be medically necessary for the treatment of gender dysphoria on a case-by-case basis.
A service or the frequency of services available to a transgender recipient cannot be categorically limited. All medically necessary services must be provided timely. Limitations and exclusions, medical necessity determinations and/or appropriate utilization management criteria that are non-discriminatory may be applied.
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