Policy Issued By: Amida Care

Policy Title: Clinical Guidelines and Coverage Criteria for the Treatment of Gender Dysphoria

Facial Reconstruction:

Requires supporting documentation that indicates specific type of FFS procedures requested.

Policy Issued By: Anthem

Policy Title: Gender Affirming Surgery

Facial Reconstruction:

Gender affirming facial surgery† is considered reconstructive when all of the following criteria have been met:

1. The individual is at least 18 years of age; and
2. The individual has capacity to make fully informed decisions and consent for treatment; and
3. The individual has been diagnosed with gender dysphoria (see Discussion section for diagnostic criteria); and
4. For individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and
5. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
6. Existing facial appearance demonstrates significant variation from normal appearance for the experienced gender; and
7. The procedure directly addresses variation from normal appearance for the experienced gender (note: each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive); and
8. One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission.

†See Discussion section for a list of procedures included in this group of procedures

Policy Issued By: Anthem Blue Cross (California)

Policy Title: Gender Affirming Surgery

Facial Reconstruction:

Gender affirming facial surgery† is considered reconstructive when all of the following criteria have been met:

1. The individual is at least 18 years of age; and
2. The individual has capacity to make fully informed decisions and consent for treatment; and
3. The individual has been diagnosed with gender dysphoria (see Discussion section for diagnostic criteria); and
4. For individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and
5. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
6. Existing facial appearance demonstrates significant variation from normal appearance for the experienced gender; and
7. The procedure directly addresses variation from normal appearance for the experienced gender (note: each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive); and
8. One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission.

†See Discussion section for a list of procedures included in this group of procedures

Policy Issued By: AvMed

Policy Title: Gender Reassignment Surgery

Facial Reconstruction:

Exclusion Criteria

The following procedures are considered cosmetic and not a covered benefit include, but are not limited to:

• Feminizing procedures including Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction of hyoid (chondroplasty), hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing.

Policy Issued By: Blue Cross Blue Shield of New Mexico

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

Facial Reconstruction:

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:

• Blepharoplasty;
• Brow lift;
• Cheek implants;
• Chin or nose implants;
• Face lift (rhytidectomy);
• Facial bone reconstruction/sculpturing/reduction, includes jaw shortening;
• Forehead lift or conturing;
• Hair removal (may include donor skin sites) or hair transplantation (electrolysis or hairplasty);
• Laryngoplasty;
• Lip reduction or lip enhancement;
• Neck tightening;
• Reduction thyroid chondroplasty or trachea shaving (reduction of Adam’s apple);
• Rhinoplasty (nose correction)
• Skin resurfacing

Policy Issued By: Blue Cross Blue Shield of Oklahoma

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

Facial Reconstruction:

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:

• Abdominoplasty;
• Blepharoplasty;
• Brow lift;
• Calf implants;
• Cheek implants;
• Chin or nose implants;
• External penile prosthesis (vacuum erection devices);
• Face lift (rhytidectomy);
• Facial bone reconstruction/sculpturing/reduction, includes jaw shortening;
• Forehead lift or contouring;
• Hair removal (may include donor skin sites) or hair transplantation (electrolysis or hairplasty);
• Laryngoplasty;
• Lip reduction or lip enhancement;
• Liposuction/lipofilling or body contouring or modeling of waist, buttocks, hips, and thighs reduction;
• Neck tightening;
• Pectoral implants;
• Reduction thyroid chondroplasty or trachea shaving (reduction of Adam’s apple);
• Redundant/excessive skin removal;
• Rhinoplasty (nose correction);
• Skin resurfacing;
• Testicular expanders;
• Voice modification surgery; and/or
• Voice (speech) therapy or voice lessons.

NOTE 4: Preparatory or ancillary procedures (such as anesthesia, tissue harvesting for skin, fat, nerve or muscle grafting, etc.) and supplies or equipment (such as stents, prosthesis, implants, etc.) that are required for the procedures listed above are considered an integral part of the MtF or FtM transition process.

NOTE 5: Surgical repairs or revisions related to MtF or FtM procedures may be required, such as removal and replacement of prostheses.

Policy Issued By: Blue Cross Blue Shield of Texas

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

Facial Reconstruction:

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:

• Abdominoplasty;
• Blepharoplasty;
• Brow lift;
• Calf implants;
• Cheek implants;
• Chin or nose implants;
• External penile prosthesis (vacuum erection devices);
• Face lift (rhytidectomy);
• Facial bone reconstruction/sculpturing/reduction, includes jaw shortening;
• Forehead lift or contouring;
• Hair removal (may include donor skin sites) or hair transplantation (electrolysis or hairplasty);
• Laryngoplasty;
• Lip reduction or lip enhancement;
• Liposuction/lipofilling or body contouring or modeling of waist, buttocks, hips, and thighs reduction;
• Neck tightening;
• Pectoral implants;
• Reduction thyroid chondroplasty or trachea shaving (reduction of Adam’s apple);
• Redundant/excessive skin removal;
• Rhinoplasty (nose correction);
• Skin resurfacing;
• Testicular expanders;
• Voice modification surgery; and/or
• Voice (speech) therapy or voice lessons.

NOTE 4: Preparatory or ancillary procedures (such as anesthesia, tissue harvesting for skin, fat, nerve or muscle grafting, etc.) and supplies or equipment (such as stents, prosthesis, implants, etc.) that are required for the procedures listed above are considered an integral part of the MtF or FtM transition process.

NOTE 5: Surgical repairs or revisions related to MtF or FtM procedures may be required, such as removal and replacement of prostheses.

Policy Issued By: BlueCross BlueShield of Western New York

Policy Title: Gender Affirming Surgery

Facial Reconstruction:

Gender affirming facial surgery† is considered reconstructive when all of the following criteria have been met:

1. The individual is at least 18 years of age; and
2. The individual has capacity to make fully informed decisions and consent for treatment; and
3. The individual has been diagnosed with gender dysphoria (see Discussion section for diagnostic criteria); and
4. For individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and
5. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
6. Existing facial appearance demonstrates significant variation from normal appearance for the experienced gender; and
7. The procedure directly addresses variation from normal appearance for the experienced gender (note: each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive); and
8. One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission.

†See Discussion section for a list of procedures included in this group of procedures

Policy Issued By: Fallon Health

Policy Title: Gender Affirmation Services

Facial Reconstruction:

There are various other procedures commonly associated with Gender Affirmation Surgery. Fallon Health recognizes these procedures bring patients into a wide range of accepted appearances of their desired gender. While Fallon Health maintains a Cosmetic Surgery Clinical Coverage Criteria policy that applies to these procedures consideration will be given to how the procedure will affect gender identity.

Policy Issued By: Harvard Pilgrim Health Care (Stride HMO Medicare Advantage)

Policy Title: Transgender Health Services

Facial Reconstruction:

Harvard Pilgrim Health Care (HPHC) considers transgender surgical services as medically necessary when documentation and confirm ALL the following for transgender genital surgery:

1. Member age 18 years or older has been diagnosed, by an appropriately trained Mental Health Professional (MHP), with gender dysphoria/gender incongruence; AND
2. Transgender surgery has been recommended by TWO treating clinicians
3. Capacity to make fully informed decision and to consent for treatment
4. If significant medical or mental health concerns are present, they must be well controlled
5. Complete 12 continuous months of hormone therapy appropriate to the member’s the desired gender (unless medically contraindicated)

Transfeminine surgeries covered include:

• Tracheoplasty
• Blepharoplasty (lower and upper eyelid)
• Blepharoptosis
• Brow Ptosis
• Rhytidectomy
• Suction assisted lipectomy
• Genioplasty
• Osteoplasty
• Otoplasty
• Rhinoplasty
• Forehead contouring
• Mandible/jaw contouring

Policy Issued By: Inland Empire Health Plan (IEHP) (Medi-Cal)

Policy Title: Gender Dysphoria

Facial Reconstruction:

Facial Reconstructive Surgical Consultation:

a. The individual must have a diagnosis of persistent gender dysphoria.

b. The individual must be 18 years of age or older.

c. The individual must be able to provide informed consent;

i. Feminizing/Masculinizing gender-affirming surgery will lead to irreversible physical changes and/or potential adverse effects, and the individual must have the capacity to make a fully informed decision to consent to treatment.

ii. The treating surgeon must show that the individual has received appropriate education prior to the proposed procedure.

d. Evidence of 12 continuous months of hormone therapy, unless medical contraindication to hormone therapy documented.

e. Member has lived as the preferred gender for 12 continuous months.

f. A Medical Evaluation Form is to be completed (see Attachment B).

Alternatively, the Provider may submit the same content in the clinical documentation.

g. The Provider or Therapist Documentation Form for Evaluation for Transgender Surgery is to be completed (see Attachment C). Alternatively, a letter from the Provider addressing the same content as Attachment C is acceptable.

i. The form/letter must evaluate facial feature(s) that cause persistent gender dysphoria, clarify goals and expectations, and assess self-acceptance, AND

ii. Address how the presence of stated feature(s) impair function in relation to activities of daily living, AND

iii. Address how reconstruction of said features will improve quality of life and daily function.

2. Facial Reconstructive Surgery requests:

a. All components of facial reconstructive consultation requests have been completed;

b. Clear documentation of proposed facial reconstructive procedures with evidence, to include photos, justifying medical necessity and reconstructive purpose of requested surgical procedure.

Policy Issued By: Mass General Brigham Health Plan

Policy Title: Gender Affirming Procedures

Facial Reconstruction:

Covered procedures when medical necessity criteria are met:

a. Forehead contouring (Osteoplasty)

b. Rhinoplasty/Septoplasty

c. Mandible/jaw contouring- reconstruction

d. Trachea shave or tracheoplasty

e. Blepharoplasty (only as needed in conjunction with other facial feminization procedures)

f. Brow lift g. Cheek augmentation

h. Rhytidectomy (Face lift) of forehead and cheek, excluding neck. Rhytidectomy is excluded for MassHealth members.

i. Genioplasty

j. Scalp (hairline) advancement

k. Lateral canthopexy

l. Lip lift

m. Lysis intranasal synechia

n. Suction-assisted lipectomy /liposuction (only as needed in conjunction with one of the above procedures).

Policy Issued By: Minnesota Health Care Programs

Policy Title: Gender-Confirming Surgery

Facial Reconstruction:

In addition to these specific covered procedures, the following procedures may also be covered when medically necessary:

• Facial surgery may be considered for coverage on a case-by-case basis. Factors that may be considered in the case-by-case analysis include:
  • How each requested procedure has a direct link to alleviating the documented symptoms of the gender dysphoria
  • Documentation showing that no other physical or behavioral health condition could be causing the distress that the facial surgery attempts to address
  • Explanation of how the symptoms will be alleviated through each requested procedure and how improvement will be measured and monitored.

Policy Issued By: Oregon Health Authority (Oregon Health Plan)

Policy Title: Prioritized List of Health Services - Gender Dysphoria/Transsexualism

Facial Reconstruction:

Individuals have received coverage for facial gender confirmation surgery under the Oregon Health Plan.

Policy Issued By: UniCare (Anthem)

Policy Title: Gender Affirming Surgery

Facial Reconstruction:

Gender affirming facial surgery† is considered reconstructive when all of the following criteria have been met:

1. The individual is at least 18 years of age; and
2. The individual has capacity to make fully informed decisions and consent for treatment; and
3. The individual has been diagnosed with gender dysphoria (see Discussion section for diagnostic criteria); and
4. For individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and
5. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
6. Existing facial appearance demonstrates significant variation from normal appearance for the experienced gender; and
7. The procedure directly addresses variation from normal appearance for the experienced gender (note: each procedure requested should be considered separately as some procedures may be cosmetic and others may be reconstructive); and
8. One letter, signed by the referring qualified mental health professional* who has independently assessed the individual, is required; the letter must have been signed within 12 months of the request submission.

†See Discussion section for a list of procedures included in this group of procedures