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: Asuris

Policy Title: Transgender Services

Permanent Hair Removal:

All of the following general criteria must be met for surgical gender affirming interventions for gender dysphoria to be considered for coverage:

A. Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); and

B. Clinical records document that the patient has the capacity to make fully informed decisions and consent for intervention, and that any other mental health condition, if present, is adequately controlled; and

C. At least 2 licensed mental health professionals have diagnosed gender dysphoria, and recommend surgical intervention (Note: only 1 mental health professional referral is required for mastectomy); and

D. Documentation of continuous hormonal therapy for at least 12 months, unless there is a documented contraindication to hormonal therapy (Notes: hormonal therapy is not required prior to mastectomy; hormonal therapy for at least 6 months is required for endometrial ablation); and

E. Twelve months of living in a role that is congruent with the patient’s identity.

Any of the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the intervention would improve otherwise documented significant gender dysphoria, and all of Criteria II.A.-E. above are met: ... 2. Hair removal

Policy Issued By: Blue Cross Blue Shield of Illinois

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 Blue Shield of Kansas

Policy Title: Sex 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, in all other situations it is cosmetic and noncovered.

Policy Issued By: Blue Cross Blue Shield of Massachusetts

Policy Title: Gender Affirming Services (Transgender Services)

Permanent Hair Removal:

Electrolysis performed by a licensed dermatologist may be considered MEDICALLY NECESSARY for the removal of hair on a skin graft donor site prior to its use in genital gender affirmation surgery.

Policy Issued By: Blue Cross Blue Shield of Minnesota

Policy Title: Gender Affirming Procedures for Gender Dysphoria

Permanent Hair Removal:

• The following procedures for the treatment of gender dysphoria may be considered MEDICALLY NECESSARY AND APPROPRIATE to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment treatment plan when criteria in section I are met:
  • Electrolysis or laser treatment for facial hair removal;

• Documentation Requirements:
  
  • One letter of recommendation from a qualified mental health professional (as defined in section I) has been obtained and includes ALL of the following:
    
    • The member’s general identifying characteristics; and
    • Results of the member’s psychosocial assessment, including any diagnoses; and
    • The duration of the mental health professional’s relationship with the member including the type of evaluation and therapy or counseling to date; and
    • An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the member’s request for surgery; and
    • A statement about the fact that informed consent has been obtained from the patient; and
    • A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.
  • The letter must be presented to the health plan and to the surgeon prior to surgery. If the providers are working within a multidisciplinary specialty team, the letters may be sent only to the health plan with documentation of the information in the patient's chart.
  • For voice modification surgery, documentation from the treating speech therapy provider that speech therapy was tried and failed, and that voice modification surgery will provide further benefit.

Policy Issued By: Blue Cross Blue Shield of Montana

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 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: Transgender 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: BridgeSpan Health

Policy Title: Gender Affirming Interventions for Gender Dysphoria

Permanent Hair Removal:

One or more of the following criteria are met: Clinical documentation is submitted expressly documenting that the intervention would improve otherwise documented significant gender dysphoria and the request is for one or more of the following procedures: Hair removal

Policy Issued By: California

Policy Title: Gender Reassignment Surgery

Permanent Hair Removal:

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):

• Electrolysis or laser hair removal for facial, or body areas other than pubic region. Reevaluation by a qualified medical provider is needed if treatment exceeds 6 months or 30 hours.
• Pubic area electrolysis or laser hair removal may be considered medically necessary when there is a recommendation from the surgeon (with documentation in the medical record) of the need to be done related to a planned genital reconstructive surgery. This treatment can be done during the same time period as hormonal therapy and living in the preferred gender role full time. Photographic and endocrinologist documentation is not required. Re-evaluation by a qualified medical provider is needed if treatment exceeds 6 months or 30 hours.

Policy Issued By: CareFirst BlueCross BlueShield

Policy Title: Gender Affirmation Services /Gender Dysphoria

Permanent Hair Removal:

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: ...

• Hair removal via electrolysis, laser, and waxing/Hair transplantation

Policy Issued By: CareSource

Policy Title: Gender Dysphoria (Georgia 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: 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 (Kentucky 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: 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: CareSource

Policy Title: Gender Dysphoria (West Virginia 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: Treatment of Gender Dysphoria

Permanent Hair Removal:

The procedures listed below are considered not medically necessary under standard benefit plan language. However, some benefit plans may expressly cover some or all of the procedures listed below for gender reassignment surgery.

Note: For New York regulated benefit plans (e.g., insured):The procedures listed below will be further reviewed on a case-by-case basis by a medical director with particular consideration given to whether the proposed procedure(s) advance an individual’s ability to properly present and function in the identified gender role. ... Electrolysis

Policy Issued By: EmblemHealth - New York

Policy Title: Gender Affirming/Reassignment Surgery - New York

Permanent Hair Removal:

Genital electrolysis is not considered a surgical procedure, but is performed in conjunction with genital surgery (i.e., when required for vaginoplasty or phalloplasty)

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:

1. Electrolysis (unless required for vaginoplasty or phalloplasty)

Policy Issued By: Empire Blue Cross Blue Shield (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 when the medical necessity criteria for phalloplasty or vaginoplasty procedures above has been met.

Policy Issued By: HMSA

Policy Title: Gender Identity Services

Permanent Hair Removal:

Pre-surgical electrolysis for the removal of hair on a skin graft prior to use in genital reassignment surgery is covered.

Policy Issued By: Harvard Pilgrim Health Care

Policy Title: Transgender Health Services

Permanent Hair Removal:

• Electrolysis or laser hair removal pre-operatively for genital reconstructive procedures (i.e. Clitoroplasty, Colovaginoplasty, Labiaplasty, Orchiectomy, Penectomy, Vaginoplasty), for a maximum of six treatment sessions
• Electrolysis or laser hair removal pre-operatively for genital reconstructive procedures (i.e. Colpectomy, Metoidioplasty, Phalloplasty, Scrotoplasty), for a maximum of six treatment sessions

Policy Issued By: Hawaii Medical Service Association

Policy Title: Gender Identity Services

Permanent Hair Removal:

Removal of hair (both electrolysis and laser) on a skin graft prior to use in gender confirmation surgery is covered.

Precertification is not required for removal of hair (both electrolysis and laser) on a skin graft prior to use in gender confirmation surgery is covered.Sessions are limited to a total of 5 visits per member.

Policy Issued By: Health Net

Policy Title: Gender Affirming Procedures

Permanent Hair Removal:

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.

• Electrolysis*
• Hair transplantation
• Hair removal

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.

For example, with respect to hair removal through electrolysis, laser treatment, or waxing, the WPATH “Statement of Medical Necessity for Electrolysis” (July 15, 2016) clarifies that patients with the same condition do not always respond to, or thrive, following the application of identical treatments. Treatment must be individualized, such as with electrolysis, and medical necessity should be determined according to the judgment of a qualified mental health professional and the referring physician.

The documentation to support the medical necessity for hair removal should include all three essential elements:

• A properly trained (in behavioral health) and competent (in assessment of gender dysphoria) professional has diagnosed the member with gender dysphoria or GID.
• The individual has completed 3 years of feminizing hormonal therapy.
• The medical necessity for electrolysis has been determined according to the judgment of a qualified mental health professional and the referring physician.

If any element remains to be satisfied before medical necessity can be determined, the individual should be directed to an appropriate network participating provider for consultation or treatment.

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: Kaiser Foundation Health Plan of Washington

Policy Title: Gender Reassignment Surgery

Permanent Hair Removal:

Requirements for facial hair removal

KP Washington will cover facial hair removal for members with documented gender dysphoria and who are transfeminine. The area of treatment is limited to the face and throat and excludes eyebrows. Member can have either electrolysis or laser hair removal or both. The member must work with the KP Transgender Case Manager to determine the best provider for the service and arrange for either insurance billing or member reimbursement for services. The member needs to have active status at the time of the service. Pt needs to be age 18 or older or have parental consent.

Unless there are medical contraindications to therapy, patients should undergo feminizing hormone therapy aimed at decreasing androgen effects prior to hair removal to enhance efficacy and prevent additional/recurrent terminal hair growth. Adequate androgen blockade can be demonstrated by ONE of the following:

a. 6 months or longer of medical therapy aimed at decreasing androgen production or effects (for example, spironolactone/ GNRH agonists/ finasteride with or without estrogen) OR

b. Serum testosterone (total) in the normal female range (<100mg/dL) OR

c. History of prior gonadectomy

Note: Patients who have not had gender reassignment surgery (gonadectomy or vaginoplasty) should continue hormone/anti-androgen therapy unless contraindicated during and after hair removal to prevent recurrence.

Policy Issued By: Kaiser Permanente Northwest Region

Policy Title: Transgender Surgery

Permanent Hair Removal:

Male-to-Female (MtF): Tracheal Shave and facial hair removal as well as surgical area hair removal by electrolysis or laser are covered when referred by a Gender Pathways provider.

Policy Issued By: LifeWise

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.

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: Medi-Cal

Policy Title: Transgender Services

Permanent Hair Removal:

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: Moda Health Plan

Policy Title: Gender Confirming Surgery

Permanent Hair Removal:

The following adjunct procedures are considered medically necessary if the specific criteria is met for the procedure requested: Hair removal for surgical reconstruction (i.e. genital hair removal) that meets ALL of the following criteria:

1. Hair removal for surgical reconstruction (i.e. genital hair removal) that meets ALL of the following criteria:
   1. Requested hair removal is prior to male to female genital surgery involving hair-bearing flabs associated with vaginoplasty due to 1 or more of the following:
      1. Skin area will be brought into contact with urine (used to construct a neourethra)
      2. Skin area to be moved to reside within a partially closed cavity within the body (e.g. used to line the neovagina)
2. Request is NOT for hair-bearing skin that remains outside of the body after gender reassignment surgery as that does not need to be removed and will NOT be covered
3. Hair removal will involve 1 or more of the following modalities which may take up to a year prior to surgery:
   1. Electrolysis
   2. Laser hair removal
4. Request is NOT for hair removal for cosmetic reasons as that is NOT a covered benefit
5. Patient meets criteria for genital surgery in section F or gender confirming facial procedures in section G.

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: UPMC Health Plan

Policy Title: Gender Affirmation Surgery

Permanent Hair Removal:

Hair removal is only considered medically necessary for any skin used to build a urethra or vagina. This is considered part of the genital surgery and will not be paid separately unless:

• The surgeon documents why they are unable to oversee or perform the procedure themselves; and
• The identified electrolysis provider must be able to perform ‘true needle electrolysis’, is certified in electrology, be an active member of the American Electrology Association (AEA), and holds an active Cosmetology License in Pennsylvania; and
• The procedure will be for permanent hair removal on skin used to build a urethra or vagina only.

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.