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Health Insurance Medical Policies - Facial Reconstruction


Below are excerpts from various health insurance medical policies that have explicit provisions detailing when facial reconstruction for transgender women and men is covered.

The fact that an insurance company is listed here does not mean that your particular plan will follow these guidelines. You must look to your individual policy to determine if transgender care is covered or excluded. Only if it is covered will the policies below apply.

Policy: Transgender Services

Facial Reconstruction:

When the criteria in II.A. above are met or have been met, the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the particular requested procedure would improve otherwise documented significant gender dysphoria: ... 3. Hair transplantation

Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

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)

Policy: Transgender Services

Facial Reconstruction:

Facial Feminization (typical components of facial feminization) or Masculinization may be considered MEDICALLY NECESSARY when ALL of the following candidate criteria are met:

  • The candidate is at least 18 years of age,
    • If the candidate is less than 18 years of age, then the treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet this criterion.
  • The candidate has been diagnosed with gender dysphoria (ICD-10 codes F64.0-F64.9 gender identity disorder), including meeting ALL of the following indications:
    • The desire to live and be accepted as a member of another sex other than one’s assigned sex, typically accompanied by the desire to make the physical body as congruent as possible with the identified sex through surgery and hormone treatment
    • The new gender identity has been present for at least 12 months
    • The gender dysphoria (ICD-10 codes F64.0-F64.9 gender identity disorder) is not a symptom of another mental disorder.
  • The candidate has completed a minimum of 12 months of successful continuous full time real-life experience in their new gender, with no returning to their original gender
    • If the candidate does not meet the 12 month time frame criteria of 12 months of successful continuous full time real-life experience in their new gender noted above, then the treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet these criteria. When submitted, the criteria of 12 months of successful continuous full time real-life experience in their new gender may be waived.
  • Covered procedures when medical necessity criteria are met:
    • Forehead contouring
    • Rhinoplasty
    • Mandible reconstruction
    • Trachea shave
    • Blepharoplasty
    • Brow lift o Cheek augmentation
    • Face lift or liposuction (only as needed in conjunction with one of the above procedures).
  • The following facial procedures are considered INVESTIGATIONAL and are not covered:
    • Lip enhancement
    • Neck lift
    • Dermabrasion
    • Chemical peel
    • Hair transplant
    • Electrolysis (except for genital surgery as noted below).
Policy: Surgical Treatment of Gender Dysphoria

Facial Reconstruction:

Surgical procedures to alter the gender-specific appearance of a member who has undergone or is planning to undergo gender reassignment surgery, include but are not limited to:

  • Facial hair removal
  • Blepharoplasty
  • Face lift
  • Facial bone reconstruction
  • Rhinoplasty
  • Liposuction
  • Reduction thyroid chondroplasty
Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

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);

• Redundant/excessive skin removal;

• Rhinoplasty (nose correction);

• Skin resurfacing

Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

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. (See related medical policies below for information regarding related procedures or services because other exclusions may apply). These procedures may include the following:

• Blepharoplasty (rejuvenation of the eyelid);

• 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);

• Lip reduction or lip enhancement;

• Neck tightening;

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

• Redundant/excessive skin removal;

• Rhinoplasty (nose correction);

• Skin resurfacing;

Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

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. (See related medical policies below for information regarding related procedures or services because other exclusions may apply). These procedures may include the following:

• Blepharoplasty (rejuvenation of the eyelid);

• 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);

• Lip reduction or lip enhancement;

• Neck tightening;

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

• Rhinoplasty (nose correction);

• Skin resurfacing

Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

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. (See related medical policies below for information regarding related procedures or services because other exclusions may apply). These procedures may include the following:

• Abdominoplasty;

• Blepharoplasty (rejuvenation of the eyelid);

• Brow lift;

• Cheek implants;

• Chin or nose implants;

• Face lift (rhytidectomy);

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

• Forehead lift or conturing; [sic]

• 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);

• Redundant/excessive skin removal;

• Rhinoplasty (nose correction);

• Skin resurfacing

Policy: Gender Reassignment Surgery

Facial Reconstruction:

Trachea shave/reduction thyroid chondroplasty: reduction of the thyroid cartilage (31899)

Policy: Gender Affirming/Reassignment Surgery — Connecticut

Facial Reconstruction:

Coverage is not available for any surgeries, services or procedures that are purely cosmetic (i.e., when performed solely to enhance appearance, but not to medically treat the underlying gender dysphoria), as per Paragraph 5, 18 NYCRR 505.2(l), of the NYS Register. The following surgery, services and procedures will be presumed to be cosmetic and will not be covered, unless justification of medical necessity is provided and prior approval is received:

1. Abdominoplasty, blepharoplasty, neck tightening or removal of redundant skin

2. breast augmentation, unless the individual has completed a minimum of 24 months of hormone therapy during which time breast growth has been negligible, or hormone therapy is medically contraindicated or the member is otherwise unable to take hormones

3. Breast, brow, face or forehead lifts

4. Calf, cheek, chin, nose or pectoral implants

5. Collagen injections

6. Drugs to promote hair growth or loss

8. Facial bone reconstruction, reduction or sculpturing (including jaw shortening) and rhinoplasty

9. Hair transplantation

10. Lip reduction

12. Thyroid chondroplasty

Policy: Gender Affirming/Reassignment Surgery — New York

Facial Reconstruction:

Coverage is not available for any surgeries, services or procedures that are purely cosmetic (i.e., when performed solely to enhance appearance, but not to medically treat the underlying gender dysphoria), as per Paragraph 5, 18 NYCRR 505.2(l), of the NYS Register. The following surgery, services and procedures will be presumed to be cosmetic and will not be covered, unless justification of medical necessity is provided and prior approval is received:

1. Abdominoplasty, blepharoplasty, neck tightening or removal of redundant skin

3. Breast, brow, face or forehead lifts

4. Calf, cheek, chin, nose or pectoral implants

5. Collagen injections

6. Drugs to promote hair growth or loss

8. Facial bone reconstruction, reduction or sculpturing (including jaw shortening) and rhinoplasty

9. Hair transplantation

10. Lip reduction

12. Thyroid chondroplasty

Policy: Gender Reassignment Surgery

Facial Reconstruction:

Medically Necessary/Reconstructive Surgery

Each of the following procedures, when used specifically to improve the appearance of an individual undergoing gender reassignment surgery or actively participating in a documented gender reassignment surgery treatment plan, must be evaluated to determine if it is medically necessary reconstructive surgery to create a normal appearance for the gender with which the member identifies. Prior to making a clinical determination of coverage, it may be necessary to consult with a qualified and licensed mental health professional and the treating surgeon.

  • Blepharoplasty
  • Facial feminization
  • Facial bone reduction
  • Hair transplantation
  • Hair removal
  • Reduction thyroid chondroplasty
  • Rhinoplasty

The above section clarifies how the plan administers benefits in accordance with the WPATH, SOC, Version 7. Provided a patient has been properly diagnosed with gender dysphoria or GID by a mental health professional or other provider type with appropriate training in behavioral health and competencies to conduct an assessment of gender dysphoria or GID, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy, certain options for social support and changes in gender expression are considered to help alleviate gender dysphoria or GID.

Policy: Gender Reassignment Services

Facial Reconstruction:

Facial feminization procedures (e.g. rhinoplasty, facial bone reconstruction, blepharoplasty, etc., and electrolysis) may be considered medically necessary as part of male to female gender reassignment when all of the following criteria are met:

  1. The individual has capacity to make fully informed decisions and consent for treatment; and
  2. The individual has been diagnosed with gender dysphoria, and exhibits all of the following:
    • The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and

    • The transsexual identity has been present persistently for at least two years; and

    • The disorder is not a symptom of another mental disorder; and

    • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and

  3. If the individual has significant, outstanding medical or mental health conditions present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and
  4. One referral from a qualified mental health professional who has independently assessed the individual; and
  5. A letter from a qualified mental health professional certifying that the individual is experiencing significant psychosocial distress due to perceived inability to pass in the community as a member of the self-identified gender; and
  6. Facial photographs (both front and side views) for facial procedures, or of the affected part of the body.
Policy: Treatment of Gender Dysphoria

Facial Reconstruction:

POTENTIALLY COSMETIC

The following procedures are considered potentially cosmetic services, unless medical necessity demonstrating a functional impairment can be identified. Services that are cosmetic are a benefit contract exclusion for all products of the Company, and therefore, not eligible for reimbursement consideration. This is not an all-inclusive list, refer to any applicable medical policies.

  • Blepharoplasty
  • Body contouring procedures (e.g., liposuction, lipectomy)
  • Botox injections
  • Calf implantation
  • Cervicoplasty/platysmaplasty
  • Chin augmentation (genioplasty, mentoplasty) 
  • Collagen injections
  • Dermabrasions/chemical peels
  • Excision of redundant skin
  • Facial masculinizing/feminizing surgeries (e.g., facial bone reduction)
  • Facial prosthesis (e.g. nasal, orbital) 
  • Forehead reduction 
  • Injectable dermal fillers (e.g., Sculptra, Radiesse)
  • Lip reduction/enhancement
  • Orthognathic procedures
  • Otoplasty
  • Rhinoplasty 
  • Rhytidectomy
  • Trachea shave/reduction thyroid chondroplasty 
Policy: Gender Dysphoria

Facial Reconstruction:

1. Facial Reconstructive Surgical Consultation:

a. The individual must have a diagnosis of persistent gender dysphoria.

b. The individual must be 18 years of age or older.

c. The individual must be able to provide informed consent. Feminizing/Masculinizing gender-affirming surgery will lead to irreversible physical changes and/or potential adverse effects, and the individual must have the capacity to make a fully informed decision to consent to treatment.

i. The treating surgeon must show that the individual has received appropriate education prior to the proposed procedure.

d. Demonstration of 12 continuous months of hormone therapy, unless medical contraindication to hormone therapy documented.

e. Member has lived as the preferred gender for 12 continuous months.

f. A Medical Evaluation Form is to be completed (see Attachment B).

Alternatively, the Provider may submit the same content in the clinical documentation.

g. The Provider or Therapist Documentation Form for Evaluation for Transgender

Surgery is to be completed (see Attachment C). Alternatively, a letter from the Provider addressing the same content as Attachment C is acceptable.

i. The form/letter must evaluate facial feature(s) that cause persistent gender dysphoria, AND

ii. Address how the presence of stated feature(s) impair function in relation to activities of daily living, AND

iii. Address how reconstruction of said features will improve quality of life and daily function.

Policy: Transgender Surgery

Facial Reconstruction:

Male-to-Female (MtF): Tracheal Shave is covered when referred by a Gender Pathways provider.

Policy: Gender Reassignment

Facial Reconstruction:

The following adjunct procedures are considered medically necessary if the specific criteria is met for the procedure requested: ... Blepharoplasty 

Policy: Transgender Services

Facial Reconstruction:

The Uniform Medical Plan covers the following procedures with prior authorization that meet medical necessity criteria: ...

2. Blepharoplasty, which also meets restorative function medical criteria;

18. Rhinoplasty, which also meets restorative function medical criteria; 

Policy: Transgender Surgery Rider Option: Associated Procedures

Facial Reconstruction:

Procedures, that may be performed in order to affect a more masculine or feminine appearance. Prior Authorization is required:

  • Facial bone reduction
  • Blepharoplasty
  • Rhinoplasty
  • Rhytidectomy
  • Osteoplasty
  • Genioplasty
  • Forehead augmentation
  • Reduction thyroid chondroplasty
Policy: Gender Identity Services

Facial Reconstruction:

The following services are considered cosmetic and do not meet criteria for medical necessity:

Coverage exceptions can be requested for review on an individual basis.

1. Blepharoplasty, body contouring (liposuction of the waist), breast enlargement procedures such as augmentation mammoplasty and implants, face-lifting, facial bone reduction, feminization of torso, hair removal, lip enhancement, reduction thyroid chondroplasty, rhinoplasty, skin resurfacing (dermabrasion, chemical peel), and voice modification surgery (laryngoplasty, cricothyroid approximation or shortening of the vocal cords), which have been used in feminization, are considered cosmetic.

2. Chin implants, lip reduction, masculinization of torso, and nose implants, which have been used to assist masculinization, are considered cosmetic.