Our Gender-Affirming Surgery Clinical Policy Bulletin (CPB) outlines the procedures that are considered medically necessary.
For members of plans regulated by the Federal Employee Health Benefits Program, the Plan will only consider the below facial feminization and body contouring services. And these services will be reviewed for medical necessity based on the criteria listed below. Any services not listed below will be based on our Gender-Affirming Surgery Clinical Policy Bulletin (CPB).
- Electrolysis/laser hair removal
- Tracheal shaves
- Laryngoplasty (voice modification surgery)
- Facial bone reduction or augmentation
- Rhinoplasty
- Forehead lift/lower hairline
- Scalp hair transplantation
- Rhytidectomy (face lift, facial liposuction, neck tightening)
- Lip enhancement or reduction
- Blepharoplasty
- Brow lift
- Cheek implants
- Chin implants
- Tissue grafts
- Tissue expander other than breast
- Suction assisted lipectomy
- Subcutaneous injection of indication specific FDA-approved filling material
- Prosthetic implant
- Adjacent tissue transfer or rearrangement
- Excision, excessing skin and subcutaneous tissue (includes lipectomy)
What’s needed to show medical necessity for facial feminization and body contouring services
These services must be precertified by the Aetna® Special Case Precertification Unit (SCPU). They require documentation to support the coverage criteria. Here’s the criteria used to determine medical necessity:
- Signed letter from a qualified mental health professional assessing the transgender/gender-diverse individual’s readiness for physical treatments; and
- Documentation of marked and sustained gender dysphoria; and
- Other possible causes of apparent gender incongruence have been excluded; and
- Mental and physical health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed; and
- Capacity to consent for the specific physical treatment; and
- 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
- Photos showing features that aren’t consistent with the member’s gender identity
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