Many gender affirming surgical procedures are considered medically necessary and covered by your plan. Our Gender-Affirming Surgery Clinical Policy Bulletin (CPB) outlines the breast and genital gender affirming procedures that are considered medically necessary. The criteria for coverage for breast and genital gender affirming surgery can be found in this CPB.
Additionally, for members of plans regulated by the Federal Employee Health Benefits Program, the Plan covers facial feminization and body contouring services listed below. These services will be reviewed for coverage based on the medical necessity criteria listed below.
- 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 of excessive 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
We’re here to help
If you have any questions, call us at 1-800-537-9384 (TTY: 711).