Policy Issued By: Amerigroup (Anthem)

Policy Title: Gender Affirming Surgery

Voice Therapy And Surgery:

Gender affirming voice modification 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 gender masculinization only: 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 vocal presentation demonstrates significant variation from normal for the experienced gender; and
7. 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.

Policy Issued By: Amida Care

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

Voice Therapy And Surgery:

Requires supporting documentation that indicates procedures requested are medically necessary.

Policy Issued By: Anthem

Policy Title: Gender Affirming Surgery

Voice Therapy And Surgery:

Gender affirming voice modification 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 gender masculinization only: 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 vocal presentation demonstrates significant variation from normal for the experienced gender; and
7. 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.

Policy Issued By: Anthem Blue Cross (California)

Policy Title: Gender Affirming Surgery

Voice Therapy And Surgery:

Gender affirming voice modification 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 gender masculinization only: 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 vocal presentation demonstrates significant variation from normal for the experienced gender; and
7. 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.

Policy Issued By: Anthem Blue Cross Blue Shield

Policy Title: Gender Affirming Surgery

Voice Therapy And Surgery:

Gender affirming voice modification 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 gender masculinization only: 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 vocal presentation demonstrates significant variation from normal for the experienced gender; and
7. 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.

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:

1. Abdominoplasty
2. Bilateral mastectomy
3. Blepharoplasty
4. Breast augmentation
5. Brow lift
6. Calf implants
7. Face lift
8. Facial bone reconstruction
9. Facial implants
10. Gluteal augmentation
11. Hair removal (for example, electrolysis or laser) and hairplasty, when the criteria above have not been met
12. Jaw reduction (jaw contouring)
13. Lip reduction/enhancement
14. Lipofilling/collagen injections
15. Liposuction
16. Nose implants
17. Pectoral implants
18. Rhinoplasty
19. Thyroid cartilage reduction (chondroplasty)
20. Voice modification surgery

Policy Issued By: AvMed

Policy Title: Gender Reassignment Surgery

Voice Therapy And Surgery:

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 Illinois

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

Voice Therapy And Surgery:

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:

• Laryngoplasty
• Voice modification surgery; and/or
• Voice (speech) therapy or voice lessons.

Policy Issued By: Blue Cross Blue Shield of Kansas

Policy Title: Sex Reassignment Surgery

Voice Therapy And Surgery:

Voice therapy and surgery are not covered.

Policy Issued By: Blue Cross Blue Shield of Kansas City

Policy Title: Treatment of Gender Dysphoria

Voice Therapy And Surgery:

When non-surgical treatments are not covered. Examples that apply to this exclusion include, but are not limited to: 

• Reproduction services including, but not limited to: sperm preservation in advance of hormone treatment or gender dysphoria surgery, cryopreservation of fertilized embryos, oocyte preservation, surrogate parenting, donor eggs, donor sperm and host uterus. (See the Reproduction exclusion in the member specific benefit plan document.) 
• Drugs* for hair loss or growth. 
• Drugs* for sexual performance for patients that have undergone genital reconstruction.  Drugs* for cosmetic purposes. 
• Hormone therapy except as described in the Covered Services section above. Gender Dysphoria (Gender Identity Disorder) 
• Voice therapy.

Policy Issued By: Blue Cross Blue Shield of Minnesota

Policy Title: Gender Affirming Procedures for Gender Dysphoria

Voice Therapy And Surgery:

• 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:
  • Voice therapy;
  • Voice modification surgery when voice/speech therapy has been ineffective;

• 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

Voice Therapy And Surgery:

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:

• Voice modification surgery; and/or
• Voice (speech) therapy or voice lessons.

Policy Issued By: Blue Cross Blue Shield of New Mexico

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

Voice Therapy And Surgery:

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:

• Laryngoplasty
• Voice modification surgery; and/or
• Voice (speech) therapy or voice lessons.

Policy Issued By: Blue Cross Blue Shield of Oklahoma

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

Voice Therapy And Surgery:

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:

• Laryngoplasty
• Voice modification surgery; and/or
• Voice (speech) therapy or voice lessons.

Policy Issued By: BlueChoice Healthplan of South Carolina

Policy Title: Gender Affirming Surgery

Voice Therapy And Surgery:

Gender affirming voice modification 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 gender masculinization only: 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 vocal presentation demonstrates significant variation from normal for the experienced gender; and
7. 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.

Policy Issued By: BlueCross BlueShield of Western New York

Policy Title: Gender Affirming Surgery

Voice Therapy And Surgery:

Gender affirming voice modification 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 gender masculinization only: 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 vocal presentation demonstrates significant variation from normal for the experienced gender; and
7. 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.

Policy Issued By: California

Policy Title: Gender Reassignment Surgery

Voice Therapy And Surgery:

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):

• Cricothyroid approximation (voice modification that raises the vocal pitch by stimulating contractions of the cricothyroid muscles with sutures)
• Laryngoplasty (reshaping of laryngeal framework)
• Voice modification surgery and voice retraining (speech therapy)

Policy Issued By: CareFirst BlueCross BlueShield

Policy Title: Gender Affirmation Services /Gender Dysphoria

Voice Therapy And Surgery:

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: ...

• Laryngoplasty: reshaping of laryngeal framework (voice modification surgery)
• Voice modification surgery/Cricothyroid approximation: voice modification that raises the vocal pitch by stimulating contractions of the cricothyroid muscle with sutures

Policy Issued By: Cigna

Policy Title: Treatment of Gender Dysphoria

Voice Therapy And Surgery:

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.

• Voice therapy/voice lessons
• Voice modification surgery

Policy Issued By: EmblemHealth - New York

Policy Title: Gender Affirming/Reassignment Surgery - New York

Voice Therapy And Surgery:

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. Voice therapy, voice lessons or voice modification surgery

Policy Issued By: Empire Blue Cross Blue Shield (Anthem)

Policy Title: Gender Affirming Surgery

Voice Therapy And Surgery:

Gender affirming voice modification 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 gender masculinization only: 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 vocal presentation demonstrates significant variation from normal for the experienced gender; and
7. 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.

Policy Issued By: Excellus Blue Cross Blue Shield

Policy Title: Gender Reassignment/Gender Affirming Surgery and Treatments

Voice Therapy And Surgery:

Based upon our assessment of the peer-reviewed literature, feminizing or masculinizing voice therapy and/or voice training services have been medically proven to be effective and, therefore, are considered medically appropriate for the treatment of gender dysphoria, when performed by a state-licensed speech-language pathologist or speech therapist. (Refer to Corporate Medical Policy # 8.01.13 Speech Pathology and Therapy).

Based upon our assessment of the peer-reviewed literature, voice modification surgery has been medically proven to be effective and, therefore, will be reviewed on a case-by-case basis by a Health Plan medical director with experience in treating patients with mental health conditions, and may be considered medically appropriate when ALL of the following criteria are met:

A. The patient has received a recommendation letter from a qualified mental health professional (refer to Policy Guidelines below).

B. The patient has been diagnosed with persistent gender dysphoria, including all of the following:

1. The patient has a desire to live and be accepted as a member of the identified gender, usually accompanied by the wish to make their body as congruent as possible with the preferred gender through surgery and hormone treatment;
2. The gender dysphoria has been present persistently for at least one year;
3. The condition is not a symptom of another mental disorder or a chromosomal abnormality; and
4. The condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The patient has the capacity to make a fully informed decision and to consent to treatment, as well as the ability to comply with all aftercare instructions, including recommended medical, surgical, nursing, and/or psychological care recommended by the individual’s providers.

D. The patient has reached the age of majority (18 years of age or older).

E. If significant medical or mental health concerns are present, they are reasonably well-controlled.

F. The patient has completed a minimum of 24 months of masculinizing hormone therapy prior to seeking voice masculinization surgery, unless hormone therapy is medically contraindicated, or the patient is otherwise unable to take hormones.

G. The patient has completed a trial of speech therapy and/or voice training services prior to seeking voice modification surgery.

H. The treatment plan includes post-operative voice training.

I. The treating physician has determined that the requested procedure is medically necessary to treat the patient’s gender dysphoria.

Policy Issued By: Gateway Health

Policy Title: Gender Transition Services

Voice Therapy And Surgery:

The following gender confirmation surgeries are eligible services when all of the above criteria are met:

A. Transwomen (male to female): ... Laryngoplasty

Policy Issued By: Geisinger Health Plan

Policy Title: Gender Dysphoria and Gender Confirmation Treatment

Voice Therapy And Surgery:

Voice modification surgery

Voice/speech therapy

Policy Issued By: HMSA

Policy Title: Gender Identity Services

Voice Therapy And Surgery:

The following services are generally not considered to be medically necessary, but will be reviewed on an individual basis in accord with Section II of this Medical Policy:

1. Voice alteration surgery;

Policy Issued By: Health Net

Policy Title: Gender Affirming Procedures

Voice Therapy And Surgery:

It is the policy of Health Net of California to consider voice modification surgery (such as laryngoplasty or shortening of the vocal cords) related to transgender dysphoria, consistent with World Professional Association for Transgender Health (WPATH) version 7 guidelines, according to the following:

A. Voice deepening surgery (eg thyroplasty) is considered medically necessary if the voice fails to deepen after 2 years of consistent masculinization hormone therapy.

B. Voice feminization surgery (cricothyroid approximation or CTA) is considered medically necessary when the following are met:

1. Documentation demonstrating the member has been diagnosed with transgenderism (as defined by WPATH) by qualified professionals;
2. Documentation that voice therapy has been provided and proven ineffective as attested to by a qualified voice therapist (trans-sensitive speech-language therapists using standard voice and communication protocols);
3. Documentation of completed pre-operative assessments by both a laryngologist and speech-language therapist who agreed to the clinical benefits in achieving transitional goals;
4. Documentation that a qualified voice and communication specialist (who is licensed and/or credentialed by the board responsible for speech therapists/speech-language pathologists) will follow the patient post-operatively to maximize the surgical outcome.

Policy Issued By: Kaiser Permanente Northwest Region

Policy Title: Physical/Occupational/Speech Therapy Medical Necessity Criteria

Voice Therapy And Surgery:

Acquisition of voice and communication skills for the transgender member, consistent with their sexual identity. The American Speech and Hearing Association states: The speech-language pathologist provides voice and communication training. The SLP will look at a variety of aspects of communication including vocal pitch, intonation and resonance and nonverbal comunication.

Policy Issued By: Medi-Cal

Policy Title: Transgender Services

Voice Therapy And Surgery:

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

Voice Therapy And Surgery:

The following adjunct procedures are considered medically necessary if the specific criteria is met for the procedure requested: ... Voice therapy/voice modification.

Policy Issued By: UPMC Health Plan

Policy Title: Gender Affirmation Surgery

Voice Therapy And Surgery:

Chondroplasty, voice modification and voice lessons will be considered when medically necessary.

Policy Issued By: UniCare (Anthem)

Policy Title: Gender Affirming Surgery

Voice Therapy And Surgery:

Gender affirming voice modification 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 gender masculinization only: 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 vocal presentation demonstrates significant variation from normal for the experienced gender; and
7. 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.

Policy Issued By: UnitedHealthcare West

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

Voice Therapy And Surgery:

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)

Voice Therapy And Surgery:

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.