CurrentMass General Brigham Health PlanPolicy N/A

Medical Policy Gender Affirming Procedures

Defines Mass General Brigham Health Plan's medical necessity criteria, covered gender-affirming surgical and related procedures (chest, genital, facial, vocal, hair removal, fertility preservation, speech therapy), prior authorization requirements, exclusions, and payer-specific variations (Medicare Advantage, MassHealth/ACO, OneCare/SCO). This is Part 1 of 2.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Policy Gender Affirming Procedures

Policy CodePolicy N/A

Change TypeRevised (multiple reviewslatest Jan 2026 off-cycle)

Effective DateOct 1, 2014

Next Review Date

Key ActionTreating specialist must request prior authorization for gender-affirming procedures and submit required behavioral health and clinical documentation as specified.

SourceLink

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POLICY UPDATE CHANGES

January 2026: Off-cycle review — updated prior authorization table, added OneCare and SCO variation, fixed code disclaimer, and updated code list.

March 2024: Clarified documentation requirements and removed the requirement for a separate surgeon letter of medical necessity; other minor clarifications.

April 2023: Multiple substantive edits — added term 'gender incongruence,' added Medicare Advantage to authorization table, changed genital surgery hormone therapy requirement to 6 continuous months, added vocal cord surgery, and other clarifications.

February 2022: Revised Genital Surgeries language to clarify eligible documenting providers; updated codes and clarified procedural items.

9Transfeminine procedures listed as covered

10Transmasculine procedures listed as covered

12Max electrolysis/laser w/o PA

2Fertility preservation storage (years)

Coverage Summary

This policy defines Mass General Brigham Health Plan's medical necessity criteria for gender-affirming care (Part 1 of 2), covering surgical procedures and related services. Covered components include surgical (chest/breast, genital, facial, reconstructive/revisions), medical/hormone therapy, hair removal (laser or electrolysis for skin used in genital surgery), speech therapy and vocal cord surgery, and fertility preservation. The policy aligns with WPATH standards and payer-specific guidance and notes payer variations including Medicare Advantage, MassHealth/ACO, and OneCare/SCO.

Policy Thresholds (selected)

Duration of Gender Dysphoria>= 6 months

Hormone therapy duration6 continuous months prior to genital surgery (unless not clinically indicated)

Recommended feminizing hormone therapy prior to breast augmentation12 months recommended (not required)

Hair removal treatments without additional PAUp to 12 electrolysis and/or laser treatments

Fertility preservation storage durationUp to 2 years

Medical-Necessity Criteria

General Coverage Criteria (Gender-affirming surgeries)

Gender-affirming surgeries are considered medically necessary when the Health Plan has received documentation of ALL of the following:

ALL of the following

A qualified behavioral health professional has completed a comprehensive psychosocial assessment
The duration of the behavioral health professional's relationship with the member, including the type of evaluation and/or psychotherapy that the member received
The member has capacity to make informed decisions and consent to treatment fully
Duration of Gender Dysphoria / Gender Incongruence: The member has had gender dysphoria / gender incongruence for at least 6 months

Coding

Informational code list (inclusion does not imply coverage)CPT

15771	Grafting of autologous fat harvested by liposuction technique to trunk/breasts, scalp, arms, and/or legs; 50 cc or less injectate
15772	Grafting of autologous fat harvested by liposuction technique; each additional 50 cc injectate
15773	Grafting of autologous fat harvested by liposuction technique to face...; 25 cc or less injectate
15774	Grafting of autologous fat; each additional 25 cc injectate
15820	Blepharoplasty, lower eyelid
15821	Blepharoplasty, lower eyelid; with extensive herniated fat pad
15822	Blepharoplasty, upper eyelid
15823	Blepharoplasty, upper eyelid; with excessive skin weighting down lid
15824	Rhytidectomy; forehead
15826	Rhytidectomy; glabellar frown lines

1–10 of 120

1/12

Codes specifically noted as not covered for Mass General Brigham ACOCPTNot Covered

15824	Rhytidectomy; forehead
15826	Rhytidectomy; glabellar frown lines
15828	Rhytidectomy; cheek, chin, and neck

Codes listed in the policy are provided for informational purposes only; inclusion does not constitute or imply coverage. The policy notes administrative updates including a January 2026 off-cycle review that updated the prior authorization table, added OneCare and SCO variations, fixed the code disclaimer, and updated the code list.

Provider Actions

Prior Authorization

Prior authorization required

Treating specialist must request prior authorization for gender-affirming procedures; authorization is required across listed commercial, Medicare Advantage, ACO/OneCare/SCO products as indicated in the policy header.

Prior Authorization

Hair removal prior authorization threshold

Prior authorization is required for more than 12 electrolysis and/or laser hair removal treatments and must include a subsequent letter of medical necessity for additional sessions.

17380

Documentation Required

Behavioral health documentation

Submit a comprehensive psychosocial assessment by a qualified behavioral health professional. Required elements include duration of the behavioral health relationship, types of evaluation and/or psychotherapy provided, DSM‑V diagnosis meeting criteria for gender dysphoria/gender incongruence, documentation of the member's capacity to consent, rationale for surgery, comorbid psychiatric diagnoses, evidence that significant mental health concerns are well controlled, and demonstrable functional progress.

Background & Evidence

Background: Mass General Brigham Health Plan describes criteria to determine medical necessity for gender-affirming procedures and aligns its criteria with WPATH and applicable payer guidance (CMS, MassHealth). The policy covers surgical care (chest/breast, genital, facial, and reconstructive revisions), medical therapy including gender-affirming hormone therapy and puberty blockers, hair removal by laser or electrolysis for skin used in genital surgery, speech therapy and Wendler glottoplasty, and fertility preservation services (oocyte, embryo, or sperm retrieval, freezing and storage). Prior authorization is required for treating specialists to request these procedures.

Label	Value
Association between surgery and mental health	Studies report association with reduced psychological distress, suicidality; many studies have methodological limitations
Cost-effectiveness	Markov model found coverage to be cost-effective (ICER $9314/QALY)
Long-term follow-up study	Park Liu YT, Samuel A, et al. Long-term outcomes after gender-affirming surgery: 40-year follow-up study. Ann Plast Surg: 2022.
WPATH Standards	World Professional Association for Transgender Health. WPATH Standards of Care ... 8th ed. Accessed January 31, 2023.
Systematic review psychological benefits	Wernick JA, Busa S, Matouk K, et al. A systematic review of the psychological benefits of gender-affirming surgery. Urol Clin North Am. 2019 Nov;46(4):475-486.

Definitions

Qualified Behavioral Health Provider: Behavioral health provider with a master's degree or higher in clinical behavioral science, competence in DSM/ICD diagnostics, ability to recognize comorbidities, documented supervised training in psychotherapy, knowledge of gender nonconforming identities, and continuing education in treatment of gender dysphoria/incongruence.

Gender-Affirming Surgery: A treatment option for people with gender dysphoria/gender incongruence that may include one or multiple procedures in conjunction with medical and psychiatric care to achieve successful behavioral and medical outcomes.

Medicare Determinations

Medicare determination: NCD 140.9 — At the time of the most recent policy review: No NCD is appropriate at this time for gender affirmation surgery for Medicare beneficiaries.

Revision History

2023-04material_change

Annual review with multiple substantive edits: added the term 'gender incongruence' throughout; added Medicare Advantage to the prior authorization table; revised chest/breast and genital surgery requirements (changed continuous hormone therapy for genital surgery to 6 months and removed requirement for a second provider); added vocal cord surgery and removed it from the exclusion list; clarified coverage criteria language and updated references and code list.

2024-03revised

Annual review clarifying documentation requirements and removed requirement for a separate surgeon letter of medical necessity; made other minor clarifying edits.

2022-02

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Policy Gender Affirming Procedures

Policy CodePolicy N/A

Change TypeRevised (multiple reviewslatest Jan 2026 off-cycle)

Effective DateOct 1, 2014

Next Review Date

Key ActionTreating specialist must request prior authorization for gender-affirming procedures and submit required behavioral health and clinical documentation as specified.

SourceLink

On This Page

The initial and evolving gender

Comorbid psychiatric diagnoses

Significant mental health concerns are well controlled

The behavioral health provider's rationale for surgery

The physician who is prescribing hormone therapy has consulted with the behavioral health provider as applicable

The degree to which the member has followed the treatment requirements to date and the likelihood of future compliance

Demonstrable progress

Demonstrable progress on consolidating the new gender identity, including improvements in the ability to function in work, and within family and interpersonal relationships
Demonstrable improvements in behavioral health issues (should they exist)

Presurgical evaluation

The surgeon has assessed that the member is likely to benefit from surgery
The surgeon has consulted with the treating qualified behavioral health provider(s) and physician treating the member
The surgeon has personally communicated with the member and validated that the member understands the ramifications of surgery, including required length of hospitalization(s), different surgical techniques and their advantages/disadvantages, limitations of surgical procedures, risks and complications, and post-surgical rehabilitation requirements

Chest/Breast Surgeries Criteria

For members 18 years or older

ALL of the following

General Coverage Criteria above are met
Transmasculine hormone therapy: For transmasculine members: no requirement for hormone therapy
Transfeminine recommendation: For transfeminine members: although not required, at least 12 months of feminizing hormone therapy is recommended prior to breast augmentation for optimal surgical results12 months (recommended)
recommended but not required
Under-18 consideration: Transmasculine members under 18: Medical Director will evaluate medical necessity on an individual basis

Genital Surgeries Criteria

For members 18 years or older

ALL of the following

General Coverage Criteria above are met
Hormone therapy prior to genital surgery: Documentation that the member has had 6 continuous months of hormone therapy as appropriate to the patient's gender goals (unless hormones are not clinically indicated for the individual)6 continuous months
unless hormones are not clinically indicated
Aim of pre-gonadectomy hormone therapy is to introduce a period of reversible estrogen or testosterone suppression before irreversible surgery

Facial Feminization/Masculinization Criteria

Mass General Brigham Health Plan covers facial feminization or masculinization when ALL of the following requirements are met:

ALL of the following

The member is at least 18 years of age
The member has been diagnosed with gender dysphoria / gender incongruence meeting DSM-V criteria by a qualified behavioral health professional and has had this condition for at least 6 months>= 6 months
Recommendation for the requested procedure is made by the qualified behavioral health professional
Co-morbid medical or behavioral health disorders are appropriately managed, reasonably controlled, and not causing symptoms of dysphoria
The member has capacity to make fully informed decisions and has consented after discussion of limitations, risks, and complications

Surgical Revisions (Reconstructive)

Reconstructive surgery following gender affirmation procedures is covered ONLY in the following conditions:

ANY of the following

To correct complications resulting from the initial surgery
To correct functional impairment resulting from initial surgery

Hair Removal (Electrolysis or Laser)

Covered when criteria are met

ALL of the following

Provider requirement: Hair removal with laser or electrolysis must be performed by a board-certified dermatologist or licensed provider for removal of hair on skin used for genital surgery
Plan/timeline documentation: Documentation is required of the plan and timeline for surgery pending completion of hair removal
Treatment limit: Up to 12 electrolysis and/or laser hair treatments will be covered if criteria above are metUp to 12 treatments
Prior authorization threshold: Prior authorization is required for greater than 12 electrolysis and/or laser hair removal treatments and should include a subsequent letter of medical necessity>12 requires prior authorization
PA must include letter of medical necessity
Cosmetic exclusion: Electrolysis/laser hair removal for any other part of the body is considered cosmetic and not covered

Fertility Services

Covered services related to fertility preservation

ALL of the following

Scope of services: Services related to fertility preservation (oocyte, embryo, or sperm retrieval, freezing and storage) are covered for up to 2 years for trans members undergoing hormonal therapy or genital affirmation surgeryUp to 2 years
Refer to Assisted Reproductive Services policy for details
Cross-reference: Refer to Assisted Reproductive Services/Infertility Services medical policy for details

Speech Therapy and Vocal Cord Surgery

Covered when the General Coverage Criteria are met

ALL of the following

Speech therapy coverage: Speech therapy to treat a communication disorder related to a gender dysphoria / gender incongruence diagnosis is covered
Wendler Glottoplasty vocal cord surgery is covered for transfeminine members when General Coverage Criteria are met
Recommendation: consult with a voice and communication specialist both prior to and after vocal cord surgery

Duration of behavioral health relationship and type of evaluation/therapy
Therapies provided and documentation of treatment
DSM‑V diagnosis meeting criteria for gender dysphoria / gender incongruence
Documentation of capacity to make informed decisions and consent
Behavioral health provider's rationale for surgery
Comorbid psychiatric diagnoses
Evidence that significant mental health concerns are well controlled
Demonstrable progress consolidating new gender identity and functional improvements

Documentation Required

Surgeon communication and presurgical evaluation

Surgeon must document a presurgical evaluation showing they assessed that the member is likely to benefit from surgery, consulted the treating qualified behavioral health provider(s) and treating physician(s) as applicable, and personally communicated with the member regarding the ramifications of surgery.

Assessed that the member is likely to benefit from surgery
Consulted with treating qualified behavioral health provider(s) and treating physician(s)
Personally communicated risks, different surgical techniques and their advantages/disadvantages
Personally communicated required length of hospitalization(s), limitations of procedures, risks and complications, and post-surgical rehabilitation requirements

Documentation Required

Hormone therapy evidence for genital surgery

Requests for genital surgeries require documentation that the member has had 6 continuous months of hormone therapy as appropriate to the patient's gender goals unless hormones are not clinically indicated for the individual.

Denial Risk

Exclusion conditions

Claims may be denied if procedures do not meet the General Coverage Criteria, are cosmetic, or are explicitly excluded in the policy.

Hair transplant
Collagen injections
Implants for calf, gluteal, or pectoral
Isolated blepharoplasty
Dermabrasion
Chemical peels
Neck lift

Gender dysphoria / gender incongruence (DSM-V): Marked difference between the individual's expressed/experienced gender and assigned gender that continues for at least six months and causes clinically significant distress or impairment.>= 6 months

Off-cycle review: revised language under Genital Surgeries to clarify that another licensed health care provider familiar with the member may document; edited facial feminization rhytidectomy language; updated codes and added wording about insertion of testicular prosthesis.

2026-01administrative_updateLatest

Off-cycle review updating the prior authorization table and adding variation for OneCare and SCO members; fixed code disclaimer and updated the code list.