Harvard Pilgrim HealthCare Medical Policy

Gender Affirming Services

STRIDEsm (HMO) MEDICARE ADVANTAGE

Subject: Gender Affirming Services

Background:

Gender affirming health services, which can involve various reconstruction surgeries, are part of the treatment approach for individuals with gender dysphoria (GD)/gender incongruence who have persistent feelings of gender discomfort and inappropriateness of their anatomical sex. Surgical procedures may include reconstruction to physical appearance and function of an individual's existing sexual characteristics.

Gender dysphoria/gender incongruence involves a difference between one's gender identity and sex designated at birth (usually based on external sexual anatomy). Gender dysphoria/gender incongruence is not the same as gender nonconformity, which refers to behaviors not matching the gender norms or stereotypes of the gender assigned at birth.

Authorization:

Prior authorization from Harvard Pilgrim StrideSM (HMO) is required for all Gender affirming Health Services.

Policy and Coverage Criteria:

Harvard Pilgrim Health Care (HPHC) considers Gender affirming surgical services as medically necessary when documentation and confirm ALL the following for Gender affirming genital surgery:

1. Member has been diagnosed, by an appropriately trained Mental Health Professional (MHP), with gender dysphoria/gender incongruence; AND
2. Gender affirming surgery has been recommended by treating TWO clinicians
3. Capacity to make fully informed decision and to consent for treatment
4. If significant medical or mental health concerns are present, they must be well controlled
5. Complete 12 continuous months of hormone therapy appropriate to the member's the desired gender(unless medically contraindicated)

Harvard Pilgrim Health Care (HPHC) considers Gender affirming surgical services as medically necessary when documentation and letters confirm ALL the following for Gender affirming breast/chest surgery:

1. Member has been diagnosed, by an appropriately trained Mental Health Professional (MHP), with gender dysphoria/gender incongruence; AND
2. Gender affirming surgery has been recommended by TWO treating clinicians
3. Capacity to make fully informed decisions and to consent for treatment
4. If significant medical or mental health concerns are present, they must be reasonably well controlled

HPHC Medical Policy

Page 1 of 11

Gender Affirming Services VE03MAR22P

Harvard Pilgrim StrideSM (HMO) policies are based on medical science and relevant information including current Medicare coverage (including National and Local Coverage Determinations),Harvard Pilgrim medical policies, and Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan materials. These policies are intended to provide benefit coverage information and guidelines specific to the Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan. Providers are responsible for reviewing the CMS Medicare Coverage Center guidance; in the event that there is a conflict between this document and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will control.

Transfeminine surgeries covered include:

Breast/Chest Surgery:

• Augmentation mammoplasty

Genital Surgery:

• Clitoroplasty
• Colovaginoplasty
• Labiaplasty
• Orchiectomy
• Penectomy
• Vaginoplasty
• Electrolysis or laser hair removal pre-operatively for genital reconstructive procedures (i.e. Clitoroplasty, Colovaginoplasty, Labiaplasty, Orchiectomy, Penectomy, Vaginoplasty), for a maximum of six treatment sessions

Facial feminization procedures:

• Tracheoplasty
• Blepharoplasty (lower and upper eyelid)
• Blepharoptosis
• Brow Ptosis
• Rhytidectomy
• Suction assisted lipectomy
• Genioplasty
• Osteoplasty
• Otoplasty
• Rhinoplasty
• Forehead contouring
• Mandible/jaw contouring

Transmasculine surgeries covered include:

Breast/Chest Surgery:

• Mastectomy (bilateral)

Genital Surgery:

• Colpectomy
• Electrolysis or laser hair removal pre-operatively for genital reconstructive procedures (i.e.
  • Colpectomy
  • Metoidioplasty
  • Phalloplasty
  • Scrotoplasty

  Hysterectomy

  • Metoidioplasty
  • Phalloplasty
  • Rhinoplasty
  • Salpingo-oophrectomy
  • Scrotoplasty with placement of testicular prostheses
  • Urethroplasty

  Note: Covered procedures must be performed by qualified providers trained in treating individuals with gender dysphoria/gender incongruence.

  Exclusions:

  Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers all other services for the treatment of gender dysphoria/gender incongruence as not medically necessary for all other indications, including but not limited to:

  • Abdominoplasty
  • Collagen injections
  • Dermabrasion
  • Chemical peels
  • Electrolysis or hair removal except when required pre-operatively for genital surgery and when policy criteria are met
  • Reversal of gender affirming surgery and all related drugs and procedures
  • Hair transplantation
  • Implantations (e.g., cheek, calf, pectoral, gluteal)
  • Lip reduction/enhancement
  • Liposuction
  • Panniculectomy
  • Removal of redundant skin
  • Silicone injections (e.g., for breast enlargement)
  • Voice modification therapy/surgery
  • Reimbursement for travel expenses

  HPHC Medical Policy

  Page 2 of 11

  Gender Affirming Services VE03MAR22P