Point32 Gender Affirming Services(Eff. beginning 2.1.24) Form

Gender-affirming surgery (GAS) refers to one or more procedures that are part of a multi-disciplinary treatment plan involving medical, surgical, and behavioral health interventions available for treatment of transgender and gender diverse (TGD) individuals. Transgender and gender diverse are broad terms that describe individuals with gender identifies or expressions that differ from assigned sex at birth. Gender affirming surgery can include chest surgery, genital surgery, facial surgery, and other procedures aimed at helping a TGD individual transition to their self-identified gender. It is recommended that gender affirming procedures should only be performed when the experience of gender incongruence is marked and sustained.

Note: For Members under the age of 18 see section below:

Gender Affirming Surgery for Members Under the Age of 18

The Plan uses guidance from the Centers for Medicare and Medicaid Services (CMS) and MassHealth for coverage determinations for its Dual Product Eligible plan Members. CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals and MassHealth Medical Necessity Determinations are the basis for coverage determinations. NCD - Gender Dysphoria and Gender Reassignment Surgery (140.9) (cms.gov) and Gender-Affirming Care for MassHealth Members | Mass.gov and is being supplemented by guidelines from the World Professional Association for Transgender Health (WPATH) Standards of Care. WPATH guidelines provide additional detail regarding medical necessity criteria.

Point32Health companies2226595Gender Affirming Services

1For gender affirming services, evidence is sufficient for coverage. In addition to the coverage of gender affirming procedures that are covered through the NCD and MassHealth, evidence is also sufficient for coverage of the following:

• surgery for Members less than 18 years of age,
• surgery for Members who have been diagnosed with gender dysphoria/gender incongruence based on an evaluation by one Qualified Health Care Professional, and
• vocal cord surgery.

WPATH is an interdisciplinary professional and educational organization responsible for producing evidence-based guidelines for gender affirming services such as behavioral, medical, and surgical management of gender diverse health.

The use of this supplemented criteria in the utilization management process will ensure access to evidence based clinically appropriate care. See References section below for all evidence accessed in the development of these criteria.

Clinical Guideline Coverage Criteria

Genital Surgery Clinical Coverage Criteria

The Plan considers surgical services as medically necessary when documentation and letters confirm ALL the following for gender affirming genital surgery:

1. Member has been diagnosed with gender dysphoria/gender incongruence based on an evaluation by one Qualified Health Care Professional who has competencies in the assessment of transgender and gender diverse people and attests to the Member’s readiness for medical/surgical treatments; and
2. Other possible causes for gender incongruence have been identified and excluded; and
3. New self-identified gender has been present for more than 12 months and Member has lived as their affirmed gender if safe to do so; and
4. Co-morbid medical or behavioral health conditions that could negatively impact the outcome of gender-affirming treatments have been assessed and are reasonably controlled; and
5. Member has the capacity to make fully informed decisions and to consent to treatment; and

Member has completed at least six months of continuous hormone therapy as appropriate to the Member’s gender goals (12 months for adolescents less than 18 years of age), unless hormone therapy is not desired or medically contraindicated (Numbers 3 and 6 may occur concurrently).

When the above criteria are met, the following genital surgical procedures to treat Gender Dysphoria are medically necessary:

• Hysterectomy
• Salpingo-oophrectomy
• Vulvectomy
• Vaginectomy
• Urethroplasty
• Metoidioplasty
• Phalloplasty*
• Penile Prosthesis
• Placement of Testicular Prosthesis
• Scrotoplasty
• Penectomy
• Clitoroplasty
• Colovaginoplasty
• Vulvoplasty
• Labiaplasty
• Orchiectomy
• Vaginoplasty

Note: Given the high rates of complications and complexity of phalloplasty surgery as compared to other gender-affirming procedures, phalloplasty is limited to those Members aged 18 and above.

Chest Surgery Clinical Coverage Criteria

The Plan considers surgical services as medically necessary when documentation and letters confirm ALL the following for gender affirming breast/chest surgery:

Gender Affirming Services

1. Member has been diagnosed with gender dysphoria/gender incongruence based on an evaluation by one Qualified Health Care Professional who has competencies in the assessment of transgender and gender diverse people and attests to the Member’s readiness for medical/surgical treatments; and
2. Other possible causes for gender incongruence have been identified and excluded; and
3. New self-identified gender has been present for more than 12 months and Member has lived as their affirmed gender if safe to do so; and
4. Co-morbid medical or behavioral health conditions that could negatively impact the outcome of gender-affirming treatments have been assessed and are reasonably controlled; and
5. Member has the capacity to make fully informed decisions and to consent to treatment; and
6. For feminizing gender affirming chest surgery only, Member has completed at least six months of feminizing hormone therapy prior to breast augmentation surgery (12 months for adolescents less than 18 years of age), unless hormone therapy is not desired or medically contraindicated; and
7. Risk factors associated with breast cancer have been assessed.

Note: For transmasculine members requesting surgical chest procedures, hormone therapy is not required.

When the above criteria are met, the following breast/chest surgery surgical procedures to treat Gender Dysphoria are medically necessary:

• Mastectomy (bilateral)
• Mammoplasty (breast augmentation)

Facial Feminization or Masculinization Surgeries

The Plan considers surgical services as medically necessary when documentation and letters confirm ALL of the following for gender affirming facial surgery:

1. Member has been diagnosed with gender dysphoria/gender incongruence based on an evaluation by one Qualified Health Care Professional who has competencies in the assessment of transgender and gender diverse people and attests to the Member’s readiness for medical/surgical treatments; and
2. Other possible causes for gender incongruence have been identified and excluded; and
3. New self-identified gender has been present for more than 12 months and Member has lived as their affirmed gender if safe to do so; and
4. Co-morbid medical or behavioral health conditions that could negatively impact the outcome of gender-affirming treatments have been assessed and are reasonably controlled;

Member has the capacity to make fully informed decisions and to consent to treatment. When the above criteria are met, the following facial feminization or masculinization surgical procedures to treat Gender Dysphoria are medically necessary:

• Blepharoplasty
• Brow Lift
• Cheek Augmentation
• Forehead and mandible/jaw contouring and reduction
• Grafting of autologous tissue
• Genioplasty
• Hairline advancement
• Lateral canthopexy
• Lip lift
• Lysis intranasal synechia
• Osteoplasty
• Rhinoplasty
• Suction assisted lipectomy
• Tracheoplasty
• Reduction thyroid chondroplasty

Hair Removal for Face/Neck

The Plan considers hair removal by laser or electrolysis for the face and neck as medically necessary when documentation and letters confirm ALL the following:

1. Member has been diagnosed with gender dysphoria/gender incongruence based on an evaluation by one Qualified Health Care Professional who has competencies in the assessment of transgender and gender diverse people and attests to the Member's readiness for medical/surgical treatments; and
2. Other possible causes for gender incongruence have been identified and excluded; and
3. New self-identified gender has been present for more than 12 months and Member has lived as their affirmed gender if safe to do so; and
4. Co-morbid medical or behavioral health conditions that could negatively impact the outcome of gender-affirming treatments have been assessed and are reasonably controlled; and
5. Member has the capacity to make fully informed decisions and to consent to treatment; and
6. Member has completed at least six months of continuous hormone therapy as appropriate to the member's gender goals (12 months for adolescents less than 18 years of age), unless hormone therapy is not desired or medically contraindicated.

Hair Removal for Genital Surgery

The Plan considers hair removal by laser or electrolysis for planned gender affirming surgical services as medically necessary when documentation and letters confirm ALL the following:

1. Member has been diagnosed with gender dysphoria/gender incongruence based on an evaluation by one Qualified Health Care Professional who has competencies in the assessment of transgender and gender diverse people and attests to the Member's readiness for medical/surgical treatments; and
2. Other possible causes for gender incongruence have been identified and excluded; and
3. New self-identified gender has been present for more than 12 months and Member has lived as their affirmed gender if safe to do so; and
4. Co-morbid medical or behavioral health conditions that could negatively impact the outcome of gender-affirming treatments have been assessed and are reasonably controlled; and
5. Member has the capacity to make fully informed decisions and to consent to treatment; and
6. Member has completed at least six months of continuous hormone therapy as appropriate to the member's gender goals (12 months for adolescents less than 18 years of age), unless hormone therapy is not desired or medically contraindicated; and
7. ...

Prior authorization must be obtained for gender affirming surgery prior to request for hair removal.

Note: Documentation must include a letter of medical necessity by the treating surgeon, indicating the size and location of the area to be treated, a timeline with the expected number of treatments and expected date of planned genital surgery.

Speech Therapy

The Plan considers voice modification and communication therapy by a licensed speech-language pathologist for a definitive diagnosis of persistent gender dysphoria as medically necessary for development of vocal characteristics (e.g., pitch, intonation, resonance, speech rate, phrasing patterns) and non-verbal communication patterns (e.g., facial expressions, laughing) that are congruent with the member’s gender identity and/or gender expression.

Vocal Cord Surgery for Voice Feminization (Glottoplasty)

The Plan considers vocal cord surgery as medically necessary for planned gender affirming surgical services when documentation and letters confirm ALL the following:

1. Member has been diagnosed with gender dysphoria/gender incongruence based on an evaluation by one Qualified Health Care Professional who has competencies in the assessment of transgender and gender diverse people and attests to the Member’s readiness for medical/surgical treatments; and
2. Other possible causes for gender incongruence have been identified and excluded; and
3. New self-identified gender has been present for more than 12 months and Member has lived as their affirmed gender if safe to do so; and
4. Co-morbid medical or behavioral health conditions that could negatively impact the outcome of gender-affirming treatments have been assessed and are reasonably controlled; and
5. Member seeks to make their voice and/or other aspects of their communication congruent with their gender identity and/or gender expression and has the capacity to make fully informed decisions and to consent to treatment; and
6. Surgery to be performed by a Ear Nose and Throat (ENT) specialist; and
7. Documentation of pre-surgical voice lessons and/or therapy by a licensed speech-language pathologist.

Gender Affirming Surgery for Members Under the Age of 18

Gender affirming medical or surgical procedures for a Member under 18 years of age may be medically necessary when the above criteria are met for the specific surgical procedure requested. In addition, ALL of the following criteria must be met:

1. There is written documentation and letters (one letter may suffice) confirming a multidisciplinary team has assessed the Member and it is the opinion of two Qualified Health Professionals that the Member is ready for surgery; and
2. Depending upon the type of surgery requested, the adolescent had been informed of the reproductive effects, including the potential loss of fertility, and available options to preserve fertility; and
3. An assessment of the minors emotional and cognitive maturity is required to provide informed consent/assent for the treatment; and Involvement of parent(s)/guardian(s) in the assessment/consent process is required unless their involvement is determined to be harmful to the adolescent or not feasible.

Limitations

The Plan considers all other services for the treatment of gender dysphoria/gender incongruence as not medically necessary for all other indications. In addition, the Plan does not cover:

• Body contouring procedures e.g., abdominoplasty, panniculectomy, lipofilling
• Collagen injections
• Dermabrasion
• Chemical peels
• Electrolysis or hair removal except for face/neck and when required pre-operatively for genital surgery and when policy criteria are met
• Hair transplantation
• Panniculectomy
• Removal of redundant skin
• Silicone injections (e.g., for breast enlargement)

Reimbursement for travel expenses

Note: Reconstructive surgery following gender affirmation procedures may be considered medically necessary to correct complications from the initial surgery or to correct functional impairment as a result of the initial surgery. When additional surgery has been recommended by a treating physician in order to decrease the Member’s dysphoria, surgery may be considered medically necessary. Surgery for the purpose of reversing the appearance of normal aging or for cosmetic purposes are considered not medically necessary.

Supporting Information Characteristics of a Qualified Health Care Professional (WPATH SOC-8)

Qualifications of Health Care Professional for assessing transgender and gender diverse adults for physical treatments (from WPATH SOC-8):

1. Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution.
2. For countries requiring a diagnosis for access to care, the health care professional should be competent using the latest edition of the World Health Organization's International Classification of Diseases (ICD) for diagnosis. In countries that have not implemented the latest ICD, other taxonomies may be used; efforts should be undertaken to utilize the latest ICD as soon as practicable.
3. Are able to identify co-existing mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence, and diversity.
4. Are able to assess capacity to consent for treatment.
5. Have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity.
6. Undergo continuing education in health care relating to gender dysphoria, incongruence, and diversity.

Note: WPATH suggests health care professionals assessing transgender and gender diverse adults seeking gender- affirming treatment liaise with professionals from different disciplines within the field of transgender health for consultation and referral.

Note: Qualified Health Care Professional can include licensed psychologist, psychiatrist, social worker, or other licensed physician credentialed in the field.

Characteristics of Health Care Professionals working with gender diverse adolescents (WPATH SOC-8)

1. Are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution.
2. Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
3. Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
4. Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender diverse adolescents.
5. Continue engaging in professional development in all areas relevant to gender diverse children, adolescents, and families.

Note: Qualified Health Care Professional can include licensed psychologist, psychiatrist, social worker, or other licensed physician credentialed in the field.

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