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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:

All of the following general criteria must be met for surgical gender affirming interventions for gender dysphoria to be considered for coverage:

A. Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); and

B. Clinical records document that the patient has the capacity to make fully informed decisions and consent for intervention, and that any other mental health condition, if present, is adequately controlled; and

C. At least 2 licensed mental health professionals have diagnosed gender dysphoria, and recommend surgical intervention (Note: only 1 mental health professional referral is required for mastectomy); and

D. Documentation of continuous hormonal therapy for at least 12 months, unless there is a documented contraindication to hormonal therapy (Notes: hormonal therapy is not required prior to mastectomy; hormonal therapy for at least 6 months is required for endometrial ablation); and

E. Twelve months of living in a role that is congruent with the patient’s identity.

Any of the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the intervention would improve otherwise documented significant gender dysphoria, and all of Criteria II.A.-E. above are met: ... 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: Gender Affirming Services (Transgender Services)

Facial Reconstruction:

Facial Procedures

Facial feminization or masculinization may be considered MEDICALLY NECESSARY when ALL of the following criteria are met:

  • Age ≥ 18
  • The member 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 gender other than one’s assigned sex, typically accompanied by the desire to make the physical body as congruent as possible with the identified gender through surgery and hormone treatment
    • The new gender identity should be present for at least 12 months.
    • The member has a consistent, stable gender identity that is well documented by their treating providers, and when possible, lives as their affirmed gender in places where it is safe to do so.
    • The gender dysphoria (ICD-10 codes F64.0-F64.9 gender identity disorder) is not a symptom of another mental disorder.
  • Covered procedures when medical necessity criteria are met:
    • Forehead contouring
    • Rhinoplasty
    • Mandible reconstruction
    • Trachea shave
    • Blepharoplasty
    • Brow lift
    • 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)
    • Vocal cord surgery.
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

These procedures are subject to contract definitions for medical necessity and appropriateness as well as contract benefits.

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 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: 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: Gender Reassignment Surgery

Facial Reconstruction:

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

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: Gender Reassignment Surgery

Facial Reconstruction:

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

Policy: Gender Reassignment Services

Facial Reconstruction:

Other surgeries for assisting in body feminization or body masculinization are generally labeled cosmetic as they provide no significant improvement in physiologic function. However, these surgeries can be considered medically necessary depending on the unique clinical situation of a given patient’s condition. These surgeries include but are not limited to:

  • Rhinoplasty: reshaping of the nose
  • Rhytidectomy: face lift
  • Blepharoplasty: removal of redundant skin of the upper and/or lower eyelids and protruding periorbital fat
  • Hair removal via electrolysis, laser, and waxing/Hair transplantation
  • Facial bone reduction: facial feminization
  • Chin augmentation reshaping or enhancing the size of the chin
  • Lip reduction/enhancement: decreasing/enlarging lip size
  • Trachea shave/reduction thyroid chondroplasty: reduction of the thyroid cartilage
  • Genioplasty
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). The following surgery, services and procedures will be reviewed on a case by case basis. It is expected that the clinical rationale for each requested procedure is specifically documented in the letter of medical necessity from the treating physician:

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 Collagen injections

5. Drugs to promote hair growth or loss

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

7. Hair transplantation

8. Lip reduction

10. Thyroid chondroplasty

Policy: Transgender Services

Facial Reconstruction:

There are various other procedures commonly associated with Transgender Surgery. Fallon Health recognizes these procedures bring patients into a wide range of accepted appearances of their desired gender. While Fallon Health maintains a Cosmetic Surgery Clinical Coverage Criteria policy that applies to these procedures consideration will be given to how the procedure will affect gender identity.

Policy: Gender Dysphoria and Gender Confirmation Treatment

Facial Reconstruction:

Facial implants, injections, or bone reduction (may be considered on a per-case basis with appropriate clinical documentation)

Policy: Transgender Health Services

Facial Reconstruction:

Harvard Pilgrim Health Care (HPHC) considers transgender surgical services as medically necessary when documentation and letters from the attending clinician(s) and mental health professional (MHP) responsible for managing the member’s hormone therapies (if appropriate) and/or other related transgender care confirm ALL the following:

  1. Member age 18 years or older has been diagnosed (by an appropriately trained MHP) with gender dysphoria/gender incongruence; AND
  2. Member wishes to make his/her body as congruent as possible with the gender identity through surgery and/or hormone replacement (if appropriate); AND
  3. Transgender surgery has been recommended by treating clinicians

Transfeminine surgeries covered include:

  • 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
Policy: Transgender Health Services

Facial Reconstruction:

Harvard Pilgrim Stride (HMO) Medicare Advantage considers transgender surgical services as medically necessary when documentation and letters from the attending clinician(s) and mental health professional (MHP) responsible for managing the member’s hormone therapies (if appropriate) and/or other related transgender care confirm ALL the following:

  1. Member age 18 years or older has been diagnosed (by an appropriately trained MHP) with gender dysphoria/gender incongruence; AND
  2. Member wishes to make his/her body as congruent as possible with the gender identity through surgery and/or hormone replacement (if appropriate); AND
  3. Transgender surgery has been recommended by treating clinicians

Transfeminine surgeries covered include:

  • Facial feminization procedures (Coverage limited to forehead contouring, mandible/jaw contouring, rhinoplasty and tracheoplasty)
  • Rhinoplasty
Policy: Gender Reassignment Surgery

Facial Reconstruction:

Medically Necessary/Reconstructive Surgery

It is the policy of Health Net of California that 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:

. 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;

i. 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.

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

d. Evidence 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, clarify goals and expectations, and assess self-acceptance, 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.

2. Facial Reconstructive Surgery requests:

a. All components of facial reconstructive consultation requests have been completed;

b. Clear documentation of proposed facial reconstructive procedures with evidence, to include photos, justifying medical necessity and reconstructive purpose of requested surgical procedure.

Policy: Transgender Surgery

Facial Reconstruction:

Male-to-Female (MtF): Tracheal Shave and facial hair removal as well as surgical area hair removal by electrolysis or laser are covered when referred by a Gender Pathways provider.

Policy: Gender Reassignment Surgery

Facial Reconstruction:

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

Policy: Gender Affirming Interventions for Gender Dysphoria

Facial Reconstruction:

Any of the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the intervention would improve otherwise documented significant gender dysphoria, and all of

Criteria II.A.-E. above are met:

3. Hair transplantation

Policy: Medical Necessity Guidelines: Transgender Surgical Procedures

Facial Reconstruction:

Tufts Health Plan may authorize the coverage of transgender surgery procedures listed in this guideline for Members who have this benefit included in their plan document when ALL of the following criteria are met:

  1. The Member has a definitive diagnosis of persistent gender dysphoria that has been made and documented by a qualified licensed mental health professional such as a licensed psychiatrist, psychologist or other licensed physician experienced in the field
  2. The Member has received continuous hormone therapy for 12 months or more under the supervision of a physician. Exceptions: The Member has a medical contraindication that is attested to by the treating endocrinologist; or when the request is mastectomy only for female to male surgery.
  3. The Member has lived as their reassigned gender full-time for 12 months or more. (Numbers 2 and 3 may occur concurrently.)
  4. The Member’s medical and mental health providers document that there are no contraindications to the planned surgery and agree with the plan (within three months of the Prior Authorization request).

When the above guidelines are met, Tufts Health Plan may authorize one or more of the following covered surgeries, up to the Member’s benefit limit:

  • Facial bone reduction
  • Blepharoplasty
  • Rhinoplasty
  • Rhytidectomy
  • Osteoplasty
  • Genioplasty
  • Forehead or cheek augmentation
  • Mandible/jaw contouring
  • Reduction thyroid chondroplasty
Policy: Gender Dysphoria and Gender Reassignment Surgery (NCD 140.9) (Medicare Advantag…

Facial Reconstruction:

In the absence of an NCD, coverage determinations for gender reassignment surgery, under section 1862(a)(1)(A) of the Social Security Act (the Act) and any other relevant statutory requirements, will continue to be made by the local Medicare Administrative Contractors (MACs) on a case-by-case basis.

Policy: Gender Dysphoria (Gender Identity Disorder) Treatment

Facial Reconstruction:

Surgical treatment for Gender Dysphoria is covered when the Eligibility Qualifications for Surgery are met:

2. Surgery to change specified secondary sex characteristics, specifically:

Thyroid chondroplasty (removal or reduction of the Adam’s Apple); and

4. Hair Removal: Hair removal related to genital reconstruction (e.g. electrolysis or laser) when part of a complete care plan and ordered by a physician.

Policy: Gender Dysphoria Treatment Excluding California

Facial Reconstruction:

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The documentation requirements outline below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.

Policy: Gender Dysphoria (Gender Identity Disorder) Treatment

Facial Reconstruction:

Coverage is available for medical, behavioral or pharmacological treatment that is Medically Necessary for Gender Dysphoria. UnitedHealthcare does not exclude or deny covered health care benefits based on associated diagnosis of Gender Dysphoria, or otherwise discriminate against the member on the basis that treatment is for Gender Dysphoria.

Policy: Gender Dysphoria (Gender Identity Disorder) Treatment

Facial Reconstruction:

Coverage is available for medical, behavioral or pharmacological treatment that is Medically Necessary for Gender Dysphoria. UnitedHealthcare does not exclude or deny covered health care benefits based on associated diagnosis of Gender Dysphoria, or otherwise discriminate against the member on the basis that treatment is for Gender Dysphoria.

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.