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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.
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.
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.
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
Demonstrable progress
Presurgical evaluation
Chest/Breast Surgeries Criteria
For members 18 years or older
ALL of the following
recommended but not required
Genital Surgeries Criteria
For members 18 years or older
ALL of the following
unless hormones are not clinically indicated
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
Surgical Revisions (Reconstructive)
Reconstructive surgery following gender affirmation procedures is covered ONLY in the following conditions:
ANY of the following
Hair Removal (Electrolysis or Laser)
Covered when criteria are met
ALL of the following
Fertility Services
Covered services related to fertility preservation
ALL of the following
Refer to Assisted Reproductive Services policy for details
Speech Therapy and Vocal Cord Surgery
Covered when the General Coverage Criteria are met
ALL of the following
| 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 |
| 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.
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.
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.
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.
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.
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.
Exclusion conditions
Claims may be denied if procedures do not meet the General Coverage Criteria, are cosmetic, or are explicitly excluded in the policy.
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
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.
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.
Annual review clarifying documentation requirements and removed requirement for a separate surgeon letter of medical necessity; made other minor clarifying edits.
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.
Off-cycle review updating the prior authorization table and adding variation for OneCare and SCO members; fixed code disclaimer and updated the code list.
PA must include letter of medical necessity