Gender affirmation treatment consists of medical and surgical treatments that change primary sex characteristics for individuals diagnosed with gender dysphoria. The treatment for gender dysphoria is for the individual to align their physical primary and/or secondary sex traits with their gender identity to the extent that alleviates the symptoms. 

Gender dysphoria is defined as a marked incongruence between one's own gender and natal gender of at least six (6) months duration manifested by a strong desire to be treated as/of a different gender (including no specified gender) and to have the sexual characteristics of a different gender.

Gender-affirming non-surgical treatment

Voice modification therapy can be considered medically necessary when ALL of the following are met;

• An individual meets the diagnostic criteria for gender dysphoria; and
• The presence of voice modification would reduce or eliminate symptoms.

Physical therapy may be considered medically necessary before or after surgical interventions under either of the following circumstances:

• To prepare the body for surgery; or
• To assist in recovery of function.

Gender-affirming non-surgical treatment not meeting the criteria as indicated in this policy is considered not medically necessary.

Gender affirmation surgery may be considered medically necessary when ALL of the following are met:

• The individual is greater than or equal to 18 years of age; and
• The individual is under the care of physicians and/or mental health providers who are able to document ALL of the following conditions:
  • The individual has the capacity to make a fully informed decision and to consent for treatment; and  
  • The individual has been diagnosed with the gender dysphoria, including ALL of the following:
    • The desire to live and be accepted as a member of another gender, usually accompanied by the wish to make their body as congruent as possible with the identified gender through medical and/or surgical gender-affirming treatment; and
    • The individual's identify has been present persistently for at lest (6) months
    • The dysphoria is not a symptom of another mental disorder; and
    • The disorder causes clinically significant distress or impairment in social, occupational, or other improtant areas of functioning.

• Any mental health conditions that could negatively impact the outcome of gender affirming medical/surgical treatments are assessed, with risks and benefits discussed, before a decision is made regarding treatment; and
• Any significant medical or mental health diagnoses must be reasonably well controlled before a decision is made regarding treatment.

NOTE: Six months of hormone therapy may be considered unless not needed or contraindicated.

Gender affirmation surgery not meeting the criteria as indicated in this policy is considered not medically necessary.

Surgical Services for Adolescents

Individuals less than 18 years of age will be considered on a case-by-case basis for breast reduction/augmentation for gender dysphoria. Supporting documentation should include:

• The individual has been assessed for any co-existing mental health concerns; and
• The individual has adequate support in place; and
• The individual meets the additional requirements above.

When ALL of the above criteria are met, the following surgeries/treatments may be considered medically necessary:

• Breast augmentation (including nipple/areolar reconstruction)
• Chest masculinization (including nipple/areolar reconstruction)
• Orchiectomy
• Clitoroplasty  
• Colovaginoplasty
• Labiaplasty
• Orchiectomy
• Penectomy
• Vaginoplasty
• Colpectomy/Vaginectomy
• Hysterectomy
• Metoidioplasty
• Penile prosthesis
• Phalloplasty
• Salpingo-oophorectomy
• Scrotoplasty
• Testicular prosthesis implantation
• Urethroplasty
• Voice modification surgery
• Laryngoplasty
• Vulvoplasty
• Hair augmentation/reconstruction/ hairplasty
• Hair removal or electrolysis
• Facial gender confirmation surgery, which may include any of the following (this is not an exhaustive list):
  • Blepharoplasty/brow reduction/brow lift
  • Chin augmentation/reshaping
  • Cheek, chin, and nose implants
  • Cricothyroid approximation
  • Facial bone reconstruction for feminization or masculinization
  • Tracheal shaving/reduction thyroid chondroplasty/thyroid cartilage reduction
  • Face lift (e.g., face, brow, etc.)
  • Forehead lift/Forehead Augmentation
  • Lip reduction/enhancement
  • Jaw/mandibular reduction/augmentation/sculpturing
  • Rhinoplasty

Note: Electrolysis/ Laser hair removal 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.

Note: Penile prosthesis surgery is typically performed at stage two (2) or three (3) of a multi-stage phalloplasty (a minimum of nine (9) months following stage one (1)).

Note: Although not a requirement, it is recommended that individuals undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth to obtain better surgical (aesthetic) results.

Surgical Revisions

Reconstructive surgery, following gender affirmation surgery may be considered medically necessary when it is performed for ANY of the following reasons: 

• Correct complications resulting from the initial surgery, or
• Correct a medical condition that resulted from the initial surgery that requires intervention, or
• Correct functional impairment resulting from initial surgery.

Reconstructive surgery following gender affirmation surgery to reverse natural signs of aging or if the individual  is not satisfied with the aesthetic result is considered cosmetic and is not medically necessary.

The following services are considered cosmetic and not covered, unless they are determined medically necessary to treat the individual’s condition by the provider who is treating the individual and are not primarily for aesthetic purposes or to reverse natural signs of aging (this is not an all-inclusive list):

• Abdominoplasty
• Collagen injections
• Gluteal augmentation
• Liposuction/body contouring/lipofilling
• Implants for body contouring other than breasts (e.g., calf)
• Pectoral Implants

Preventive Medicine GRS

Please refer to the member specific benefit plan for screenings (e.g., mammogram, routine gynecological examination, pap smear).

Preventive services are subject to the terms of the member’s individual or group customer benefit.