Gender Affirming Surgical Care 

I. Policy/criteria:

Gender reassignment surgery, including pre- and post-surgical hormone therapy, is considered medically necessary when ALL of the following criteria are met:

1.     Age 18 or older, AND

2.     Has confirmed gender dysphoria confirmed by counselor/physician, AND

3.     Is an active participant in a recognized gender affirming treatment program, AND

4.     Capacity to make a fully informed decision and to consent for treatment.

If medically necessary criteria for coverage for gender reassignment surgery are met, the following conditions of coverage apply.

A.    Breast surgery (i.e. initial mastectomy, breast reduction) is considered medically necessary for female to male patients when there is one letter of support from a qualified mental health professional.

Note that a trial of hormone therapy is not a pre-requisite to qualifying for a mastectomy.

B.    Gonadectomy (hysterectomy and salpingo-oophorectomy in female-to-male and orchiectomy in male-to-female patients) when BOTH of the following additional criteria are met:

1.     Recommendation for sex reassignment surgery (i.e. genital surgery) by two qualified mental health professionals with written documentation submitted to the physician performing the genital surgery (at least one letter should be a comprehensive report). Two separate letters or one letter with two signatures is acceptable. One letter from a Master’s degree mental health professional is acceptable if the second letter is from a psychiatrist or Ph.D. clinical psychologist, AND

2.     Documentation of at least 12 months of continuous gender confirming hormone therapy.

C.    Genital Reconstructive surgery (i.e., including colpectomy vaginectomy, urethroplasty, metoidioplasty with initial phalloplasty, scrotoplasty, and placement of a testicular prosthesis and erectile prosthesis in female to male patients; including colovaginoplasty penectomy, vaginoplasty, labiaplasty, and clitoplasty repair of introitus, construction of vagina with graft, coloproctostomy in male to female patients) when ALL of the following criteria are met:

1.     Recommendation for sex reassignment surgery (i.e. genital surgery) by two qualified mental health professionals with written documentation submitted to the physician performing the genital surgery (At least one letter should be a comprehensive report). Two separate letters or one letter with two signatures is acceptable. One letter from a Master’s degree mental health professional is acceptable if the second letter is from a psychiatrist or Ph.D. clinical psychologist, AND

2.     Documentation of at least 12 months of continuous hormonal sex reassignment therapy (May be simultaneous with real life experience), AND

3.     The individual has lived within the desired gender role for at least 12 continuous months, which includes a wide range of life experiences and events (e.g. family events, holidays, vacations, season-specific work or school experiences), including notification to partners, family, friends, and community members (e.g, at school, work, other settings) of their identified gender.

D.    Procedures associated with gender reassignment surgery that are performed solely for the purpose of improving or altering appearance or self-esteem related to one’s appearance are considered cosmetic in nature and not medically necessary.

The following are considered cosmetic in nature and not medically necessary when performed as a component of a gender reassignment, even when there is a benefit for gender reassignment surgery (this list may not be all-inclusive):

·         Blepharoplasty, brow reduction, brow lift

·         Breast enlargement procedures, including augmentation

·         Chin augmentation (reshaping or enhancing the size of the chin)

·         Chin, nose, forehead lift

·         Facial reconstruction for feminization or masculinization

·         Forehead augmentation

·         Gluteal and hip augmentation

·         Hair reconstruction (removal or transplantation)

·         Jaw/mandibular reduction or augmentation

·         Liposuction or enhancement

·         Mastopexy

·         Nipple/areola reconstruction

·         Pectoral implants

·         Rhinoplasty

·         Skin resurfacing (e.g. dermabrasion, chemical peel)

·         Trachea shave (Adam’s apple shaving) or reduction thyroid chondroplasty

·         Voice modification surgery

Approved:  3/20