Cigna Gender Dysphoria Treatment - State Guidelines Form

0266 Gender Dysphoria Treatment

State Specific Guidelines

Link to Medical Coverage Policy: Gender Dysphoria Treatment

Effective date: 1/1/2024

Introduction:

Coverage for treatment of gender dysphoria, including gender reassignment surgery and related services may be governed by state and/or federal mandates. The following tables detail the applicable State Specific requirements for gender dysphoria treatment.

Table of Requirements by State

State

Requirements

Colorado

For regulated plans with Essential Health Benefits (EHB)(e.g., individual, non GF small group) the following feminization/masculinization procedures are classified as medically necessary for coverage under the EHB benefit plan effective 1/1/23:

Feminization/Masculinization Procedures

• CPT/HCPCS Code Blepharoplasty (eye and lid modification)
• Face/forehead and/or neck tightening
• Facial bone remodeling for facial feminization

15820, 15821, 15822, 15823

15824, 15825, 21137, 21138, 21139, 21208, 21209

21141, 21142, 21145, 21146, 21147, 21150, 21151, 21153, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21188, 21209

• Genioplasty (chin width reduction)

21120, 21121, 21122, 21123

• Rhytidectomy (cheek, chin, and neck)
• Cheek, chin, and nose implants

17999, 21210, 21270, 30400, 30410, 15824, 15825, 15826, 15828

• Lip lift/augmentation
• Mandibular angle augmentation/creation/reduction (jaw)
• Orbital recontouring

30420, 30430

30435, 30450

40799

21120, 21121, 21122, 21123, 21125, 21127, 21193

21244

21172, 21175, 21179, 21180

"Cigna Companies" refers to operating subsidiaries of Cigna Corporation. All products and services are provided exclusively by or through such operating subsidiaries, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. © 2024 Cigna.

State

Requirements

New York1

For regulated benefits (e.g., insured): the procedures listed in the coverage policy in the section titled "Table 2: Gender Reassignment Surgery: Other Procedures" (i.e., blepharoplasty, brow lift, cheek/malar implants, collagen injections, face lift, forehead reduction/contouring, hair removal/hair transplantation, jaw reduction/contouring, laryngoplasty, lip lift/filling, rhinoplasty, skin resurfacing, thyroid reduction chondroplasty, neck tightening, electrolysis procedures other than pre-genital reconstruction, removal of redundant skin of the face, suction assisted lipoplasty, lipofIlling or liposuction, voice therapy, lesson, modification surgery) 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. In addition, for New York regulated benefit plans (e.g., insured): case-by-case review by a medical director for individuals under 18 years of age will be given.

Oregon

For regulated benefit plans (e.g., insured): facial feminization surgeries, and other facial gender affirming treatment, such as tracheal shaves, hair electrolysis, and other care such as mastectomies, breast reductions, breast implants, or any combination of gender affirming procedures, including revisions to prior treatment cannot be the subject of a blanket exclusion.

Washington

For regulated benefit plans (e.g., insured): facial feminization surgeries, and other facial gender affirming treatment, such as tracheal shaves, hair electrolysis, and other care such as mastectomies, breast reductions, breast implants, or any combination of gender affirming procedures, including revisions to prior treatment cannot be the subject of a blanket exclusion. All such services will be reviewed on a case-by-case basis by a medical director and a health care provider with experience prescribing or delivering gender affirming treatment who will confirm the appropriateness of any adverse benefit determination.

Note:

1. New York regulated benefit plans do not include exclusions or plan language that limit coverage.
2. Washington State regulated benefit plans are subject to mandated coverage criteria.

"Cigna Companies" refers to operating subsidiaries of Cigna Corporation. All products and services are provided exclusively by or through such operating subsidiaries, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. © 2024 Cigna.