Effective October 01, 2023
Coverage eligibility of Gender Affirming Surgery for Gender Dysphoria is a contract-specific benefit issue.
When benefits for gender affirming surgery are available, coverage may vary and under some plans may be excluded.
For those plans providing benefits, pre-determination of benefits is recommended prior to any gender affirming surgery.
When benefits are available, the following member criteria AND provider documentation criteria must be met:
Member Criteria:
1. The candidate is at least 18 years of age; AND
2. Has been diagnosed with gender dysphoria AND meet all the following indications:
2.1. The desire to live and be accepted as a member of the opposite sex (typically accompanied by the desire to make the physical body as congruent as possible with the identified sex through surgery and hormone treatment); AND
2.2. The new gender identity has been present for at least 12 months; AND
2.3. The gender identity disorder is not a symptom of another mental disorder or a chromosomal abnormality; AND
2.4. The gender identity disorder causes clinical distress or impairment in social, occupational, or other important areas of functioning; AND
3. For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is (Note: For candidates requesting female to male surgery see item 4 below):
3.1. Recommended by a mental health professional; AND
3.2. Provided under the supervision of a physician and the supervising physician indicates that the patient has taken the hormones as directed; AND
4. For candidates requesting female to male surgery only:
4.1. When the initial requested surgery is solely a mastectomy, the treating physician may indicate that no hormonal treatment (as described in criteria 3 above) is required prior to performance of the mastectomy. In this case, the 12-month requirement for hormonal treatment will be waived only when all other criteria contained in this policy and in the member’s health benefit plan are met; AND
5. The candidate has completed a minimum of 12 months of successful continuous full time real-life experience in their new gender, without returning to their original gender; OR
6. If the candidate does not meet the 12-month time frame criteria as noted in item 5 above, the treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet these criteria. When submitted, the criteria in item 5 will be waived unless the criteria noted in item 5 above are specified as required in the candidate’s health benefit plan.
Provider Documentation Criteria:
Treating clinicians must provide the following documentation:
1. Letter(s) that attest to the psychological aspects of the candidate’s gender dysphoria must be submitted from a behavioral health provider(s) with a master’s degree or its equivalent in a clinical behavioral health field who is capable of adequately evaluating if the candidate has any co-morbid psychiatric conditions
1.1 One behavioral health provider letter is required for breast/chest surgery (mastectomy or augmentation) as a stand-alone procedure.
1.2 Two behavioral health provider letters are required for genital surgery (submitted either in the form of two separate letters OR one letter signed by two behavioral health clinicians); AND
2. Medical records must be submitted from the candidate’s primary care provider that document medical care of the candidate for a minimum of 12 months
[Note: if the candidate has not been treated continuously by one clinician for 12 months but has transferred care from one clinician to a second clinician, then both clinicians must submit documentation and their combined treatment must have been for 12 months. If the candidate has not been under the care of one or more clinicians for 12 months, then all clinicians who provided care for the candidate during any portion of the previous 12 months must submit any available medical record along with documentation as described in the section below]; AND
3. Medical records must be submitted by the treating surgeon and must contain the required information described below.
The letter(s) and/or medical records from the candidate’s treating clinicians must document the following:
1. Whether the author of the letter is part of a gender identity disorder treatment team; AND
2. The candidate’s general identifying characteristics; AND
3. The initial and evolving gender, sexual, and other psychiatric diagnoses; AND
4. The duration of their professional relationship including the type of psychotherapy or evaluation that the candidate underwent; AND
5. The eligibility criteria that have been met by the candidate; AND
6. The physician or mental health professional’s rationale for surgery; AND
7. The degree to which the candidate has followed the treatment and experiential requirements to date and the likelihood of future compliance; AND
8. The extent of participation in psychotherapy throughout the 12-month real-life trial, (if such therapy is recommended by a treating medical or behavioral health practitioner); AND
9. That during the 12-month, real-life experience (for candidates not meeting the 12-month candidate criteria as noted in 5 and 6, the letter should still comment on the candidate’s ability to function and experience in the desired gender role), persons other than the treating therapist were aware of the candidate’s experience in the desired gender role and could attest to the candidate’s ability to function in the new role; AND
10. Demonstrable progress on the part of the candidate in consolidating the new gender identity, including improvements in the ability to handle:
1. Work, family, and interpersonal issues
2. Behavioral health issues, should they exist. This implies satisfactory control of issues such as:
2.1. Sociopathy
2.2. Substance abuse
2.3. Psychosis
2.4. Suicidality
The letter or letters from the treating surgeon must confirm that:
1. The candidate meets the “candidate criteria” listed in this policy; AND
2. The treating surgeon feels that the candidate is likely to benefit from surgery; AND
3. The surgeon has personally communicated with the treating mental health provider or physician treating the candidate; AND
4. The surgeon has personally communicated with the candidate and that the candidate understands the ramifications or surgery, including:
4.1. Required length of hospitalizations; and
4.2. Possible complications of the surgery; and
4.3. Post-surgical rehabilitation requirements of the various surgical approaches and the planned surgery.
When benefits are available, the following gender affirming surgeries---alone or in combination-- are covered:
- Hysterectomy
- Salpingo-oophorectomy
- Ovariectomy
- Orchiectomy
- Metoidioplasty
- Mastectomy or mammoplasty reduction (only for female-to-male gender transition)
- Breast augmentation (implants/lipofilling) in male-to-female gender transition
- Phalloplasty
- Vaginoplasty
- Penectomy
- Clitoroplasty
- Labiaplasty
- Vaginectomy
- Scrotoplasty Urethroplasty
- Placement of testicular prostheses
- Placement of penile prosthesis
Transgender Surgery Exclusions:
The following procedures are considered cosmetic 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:
- Abdominoplasty
- Blepharoplasty
- Brow lift
- Calf implants
- Electrolysis
- Face lift
- Facial bone reconstruction
- Facial implants
- Gluteal augmentation
- Hair removal/hairplasty when the criteria above have not been met
- Jaw reduction (jaw contouring)
- Lip reduction/enhancement
- Lipofilling/collagen injections
- Liposuction
- Nose implants
- Pectoral implants
- Rhinoplasty
- Thyroid cartilage reduction (chondroplasty)
- Voice modification surgery
- Voice therapy
Other surgery exclusions include but are not limited to:
- Autologous tissue flap breast reconstructions
- Any services performed to reverse gender affirming surgery
- Gender affirming surgical procedures not addressed as covered above and/or gender affirming surgical procedures billed with codes not listed in this medical coverage policy