Policy Issued By: Blue Cross Blue Shield of Illinois

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 Minnesota

Policy Title: Gender Affirming Procedures for Gender Dysphoria

Body Contouring:

Surgical procedures to alter the gender-specific appearance of a member who has undergone or is planning to undergo gender reassignment surgery, include but are not limited to: ...

• Liposuction

These procedures are subject to contract definitions for medical necessity and appropriateness as well as contract benefits.

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 Oklahoma

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;
• Skin resurfacing;

Policy Issued By: Blue Cross Blue Shield of Texas

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 Shield of 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: CareFirst BlueCross BlueShield

Policy Title: Gender Affirmation Services /Gender Dysphoria

Body Contouring:

Other surgeries for assisting in body feminization or body masculinization are generally labeled cosmetic as they provide no significant improvement in physiologic function. However, these surgeries can be considered medically necessary depending on the unique clinical situation of a given patient’s condition. These surgeries include but are not limited to: ...

• Gluteal augmentation via implants and lipofilling
• Liposuction/Lipoplasty: removal of fat and/or contour modeling
• Lipofilling
• Pectoral implants

Policy Issued By: ConnectiCare

Policy Title: Gender Affirming/Reassignment Surgery (Commercial)

Body Contouring:

The following surgery, services and procedures will be reviewed on a case by case basis.

It is expected that the clinical rationale for each requested procedure is specifically documented in the letter of medical necessity from the treating physician:

• Calf, cheek, chin, nose or pectoral implants Collagen injections
• Liposuction

Policy Issued By: EmblemHealth - New York

Policy Title: Gender Affirming/Reassignment Surgery — New York

Body Contouring:

Coverage is not available for any surgeries, services or procedures that are purely cosmetic (i.e., when performed solely to enhance appearance, but not to medically treat the underlying gender dysphoria). The following surgery, services and procedures will be reviewed on a case by case basis. It is expected that the clinical rationale for each requested procedure is specifically documented in the letter of medical necessity from the treating physician: ... Liposuction

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: 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.

Policy Issued By: UnitedHealthcare West

Policy Title: Gender Dysphoria (Gender Identity Disorder) Treatment (Oregon)

Body Contouring:

Coverage is available for medical, behavioral or pharmacological treatment that is Medically Necessary for Gender Dysphoria. UnitedHealthcare does not exclude or deny covered health care benefits based on associated diagnosis of Gender Dysphoria, or otherwise discriminate against the member on the basis that treatment is for Gender Dysphoria.

Policy Issued By: UnitedHealthcare West

Policy Title: Gender Dysphoria (Gender Identity Disorder) Treatment (Washington)

Body Contouring:

Coverage is available for medical, behavioral or pharmacological treatment that is Medically Necessary for Gender Dysphoria. UnitedHealthcare does not exclude or deny covered health care benefits based on associated diagnosis of Gender Dysphoria, or otherwise discriminate against the member on the basis that treatment is for Gender Dysphoria.

Policy Issued By: UnitedHealthcare West

Policy Title: Gender Dysphoria Treatment Excluding California (Oklahoma, Oregon, Texas, Washington)

Body Contouring:

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The documentation requirements outline below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.