Gender affirming surgery is considered medically necessary for the treatment of individuals with gender dysphoria when the following criteria is met:
1. Reached at least 21 years of age, and
2. Insured must have the ability to make a fully informed decision and give consent for treatment, and
3. Have been diagnosed with persistent gender dysphoria,
4. Lived continuously for at least 6 months in the gender role (real-life experiences) that is consistent with the preferred gender, without periods of time to return to the original sex of the person, and
5. Completed at least 12 months of continuous hormonal of any male to female (MTF) or female to male (FTM)* and
6. Subjected to a urological examination to identify and treat genitourinary anomalies**, and
7. One referral from a qualified health professional is needed for surgery.
*Note: A trial of hormone therapy is not required to qualify for a mastectomy.
**Note: Only recommended for genitourinary surgeries
The following gender affirming services are considered medically necessary for a person who has met the selection criteria mentioned above:
Male to female
• Clitoroplasty
• Coloproctostomy
• Colovaginoplasty
• Labiaplasty
• Orchiectomy
• Penectomy
• Perineoplasty
• Investment of penile skin
• Repair of the introit
• Urethroplasty
• Vaginoplasty with vaginal construction with graft, and/or vulvoplasty
• Total breast reconstruction
• Voice modification (surgery or therapy)
• Elimination of hair on thorax
• Flaps, grafts, and/or tissue transfer directly related to a genital reconstructive procedure
Female to male
• Hysterectomy
• Metoidioplasty
• Phalloplasty
• The placement (and removal if necessary) of an implantable erectile prosthesis
• The placement of testicular prostheses
• Salpingo-oophorectomy
• Subcutaneous mastectomy
• Vaginectomy, also known as colpectomy
• Vulvectomy
• Urethroplasty
• Urethromeatoplastia
• Scrotoplasty
• Testicular expanders
• Flaps, grafts, and/or tissue transfer directly related to a genital reconstructive procedure
The following procedures or services are considered cosmetic or not medically necessary when used to improve the gender of a person who intends to undergo, or has undergone gender affirming surgery, including but not limited to:
• Abdominoplasty
• Blepharoplasty
• Brow lift
• Cheek implants
• Nose or chin implants
• Collagen injections
• Facelift
• Facial reconstruction bone / sculpture / reduction, including shortening of the jaw
• Forehead or conturing
• Hair transplant
• Reducing lips or lip augmentation
• Liposuction or body conturing
• Rhytidectomy
• Reduction or shaving trachea, thyroid chondroplasty
• Elimination of redundant skin
• Rhinoplasty
• Skin rejuvenation
• Voice modulation theraphy
Psychotherapy is not necessary for the gender affirming surgery, except when the initial assessment of mental health professional recommends psychotherapy that specifies treatment goals, estimates of frequency and duration throughout the real life experience.
