Policy Issued By: Amida Care

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

Permanent Hair Removal:

Requires clinical documentation establishing service is medically necessary and not cosmetic.

Policy Issued By: Anthem

Policy Title: Gender Affirming Surgery

Permanent Hair Removal:

The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary.

Policy Issued By: Anthem Blue Cross (California)

Policy Title: Gender Affirming Surgery

Permanent Hair Removal:

The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary.

Policy Issued By: Anthem Blue Cross Blue Shield

Policy Title: Gender Affirming Surgery

Permanent Hair Removal:

The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary.

Policy Issued By: Blue Cross Blue Shield of New Mexico

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

Permanent Hair Removal:

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:

• Hair removal (may include donor skin sites) or hair transplantation (electrolysis or hairplasty);

Policy Issued By: Blue Cross and Blue Shield of Nebraska

Policy Title: Gender Reassignment Surgery

Permanent Hair Removal:

The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary.

Policy Issued By: CareSource

Policy Title: Gender Dysphoria (Georgia Medicaid)

Permanent Hair Removal:

Hair removal may be simultaneously approved with genital surgery based on medical necessity when skin flap area contains hair needing to be removed

SERVICES REQUIRING MEDICAL NECESSITY REVIEW

Hair removal

1. All members requesting ANY of the hair removal procedures for anticipated skin flap areas to create the new structures (does not include the perineum)
   1. Creation of a neovagina in MtF (does not include vulvoplasty alone)
   2. Creation of a neophallus in FtM

Policy Issued By: CareSource

Policy Title: Gender Dysphoria (Indiana Medicaid)

Permanent Hair Removal:

Hair removal may be simultaneously approved with genital surgery based on medical necessity when skin flap area contains hair needing to be removed

SERVICES REQUIRING MEDICAL NECESSITY REVIEW

Hair removal

1. All members requesting ANY of the hair removal procedures for anticipated skin flap areas to create the new structures (does not include the perineum)
   1. Creation of a neovagina in MtF (does not include vulvoplasty alone)
   2. Creation of a neophallus in FtM

Policy Issued By: CareSource

Policy Title: Gender Dysphoria (Ohio Marketplace)

Permanent Hair Removal:

Hair removal may be simultaneously approved with genital surgery based on medical necessity when skin flap area contains hair needing to be removed

SERVICES REQUIRING MEDICAL NECESSITY REVIEW

Hair removal

1. All members requesting ANY of the hair removal procedures for anticipated skin flap areas to create the new structures (does not include the perineum)
   1. Creation of a neovagina in MtF (does not include vulvoplasty alone)
   2. Creation of a neophallus in FtM

Policy Issued By: Cigna

Policy Title: Gender Dysphoria Treatment

Permanent Hair Removal:

Hair removal is not covered unless related to genital surgery.

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

Policy Title: Gender Dysphoria

Permanent Hair Removal:

Please refer to UM Subcommittee Approved Guideline Hair Removal for hair reduction consultation and procedure authorization criteria.

Policy Issued By: LifeWise

Policy Title: Gender Transition/Affirmation Surgery and Related Services

Permanent Hair Removal:

Hair removal procedures (including electrolysis) may be considered medically necessary to treat tissue donor sites prior to phalloplasty or vaginoplasty.

Policy Issued By: Mass General Brigham Health Plan

Policy Title: Gender Affirming Procedures

Permanent Hair Removal:

Mass General Brigham Health Plan covers hair removal with laser or electrolysis, by a board-certified dermatologist or licensed provider for removal of hair on skin being used for genital gender affirmation surgery. Documentation, including a letter of medical necessity by the treating surgeon, is required which attests to the plan and timeline for surgery pending completion of hair removal. Reimbursement for up to 12 electrolysis and/or laser hair treatments will be approved if criteria above are met. Prior authorization is required for greater than 12 electrolysis and/or laser hair removal treatments and should include a subsequent letter of medical necessity. Electrolysis/laser hair removal for any other part of the body is considered cosmetic and not covered for commercial and QHP members.

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

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

Permanent Hair Removal:

Electrolysis (CPT 17380) and laser hair removal (CPT 17110,17111) are only included on this line as part of pre-surgical preparation for chest or genital surgical procedures also included on this line. These procedures are not included on this line for facial or other cosmetic procedures or as pre-surgical preparation for a procedure not included on this line.

Policy Issued By: UniCare (Anthem)

Policy Title: Gender Affirming Surgery

Permanent Hair Removal:

The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary.

Policy Issued By: UnitedHealthcare

Policy Title: Gender Dysphoria Treatment (Commercial Plans)

Permanent Hair Removal:

Laser or electrolysis hair removal in advance of genital reconstruction prescribed by a physician for the treatment of gender dysphoria

Policy Issued By: UnitedHealthcare

Policy Title: Gender Dysphoria Treatment (Community Plan)

Permanent Hair Removal:

Laser or electrolysis hair removal in advance of genital reconstruction prescribed by a physician for the treatment of gender dysphoria

Policy Issued By: UnitedHealthcare West

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

Permanent Hair Removal:

Laser or electrolysis hair removal in advance of genital reconstruction prescribed by a physician for the treatment of gender dysphoria

Policy Issued By: Visiant (Medicare Advantage Medical Policy for Premera Blue Cross)

Policy Title: Gender Reassignment Surgery

Permanent Hair Removal:

Hair removal procedures (including electrolysis) may be considered medically necessary to treat tissue donor sites prior to phalloplasty or vaginoplasty.