Blue Cross Blue Shield of Illinois

Policy Number
SUR717.001
Policy Issued In
Illinois
Last Update
Breast Reconstruction

Male-to-Female (MtF) surgical procedures performed as part of gender reassignment services for an individual who has met the above criteria for gender dysphoria may be considered medically necessary and include the following:

• Breast modification, including but not limited to breast enlargement, breast augmentation, mastopexy, implant insertion, and silicone injections, and nipple or areola reconstruction;

Permanent Hair Removal

Procedures or services to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment services treatment plan may be considered medically necessary for the treatment of gender dysphoria ONLY.  These procedures may include the following:

• Hair removal (may include donor skin sites) or hair transplantation (electrolysis or hairplasty);

Facial Reconstruction

Procedures or services to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment services treatment plan may be considered medically necessary for the treatment of gender dysphoria ONLY.  These procedures may include the following:

• Blepharoplasty;

• Brow lift;

• Cheek implants;

• Chin or nose implants;

• Face lift (rhytidectomy);

• Facial bone reconstruction/sculpturing/reduction, includes jaw shortening;

• Forehead lift or conturing;

• Hair removal (may include donor skin sites) or hair transplantation (electrolysis or hairplasty);

• Laryngoplasty;

• Lip reduction or lip enhancement;

• Neck tightening;

• Reduction thyroid chondroplasty or trachea shaving (reduction of Adam’s apple);

• Rhinoplasty (nose correction)

Voice Therapy And Surgery

Procedures or services to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment services treatment plan may be considered medically necessary for the treatment of gender dysphoria ONLY.  These procedures may include the following:

• Voice modification surgery; and/or

• Voice (speech) therapy or voice lessons.

Body Contouring

Procedures or services to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment services treatment plan may be considered medically necessary for the treatment of gender dysphoria ONLY.  These procedures may include the following:

• Abdominoplasty;

• Calf implants;

• Liposuction/lipofilling or body contouring or modeling of waist, buttocks, hips, and thighs reduction;

• Pectoral implants;

• Redundant/excessive skin removal;

• Skin resurfacing;

Fertility Preservation

Procurement, cryopreservation/freezing, storage/banking, and thawing of reproductive tissues, such as oocytes, ovaries, embryos, spermatozoa, and testicular tissue may be considered medically necessary for individuals with gender dysphoria because gender reassignment services, such as long-term cross-sex hormone therapy or surgical procedures, may render an individual infertile whether or not the individual has reproduced in the past.

See related policy:

OB402.023 Reproductive Technologies or Techniques and Related Services

Youth Services

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

• Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);

• Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or

• Chest surgery for FtM individuals.