ModifiedMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Hair Removal

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This policy governs MassHealth medical-necessity and prior-authorization requirements for non-presurgical hair removal, particularly laser hair removal and electrolysis, when used to treat gender dysphoria. Hair removal for other diagnoses is evaluated case by case, while cosmetic hair removal is not considered medically necessary.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Hair Removal

Policy CodePolicy N/A

Change TypeModified

Effective DateSep 1, 2021

Next Review DateN/A

Key ActionProviders must electronically submit the prior-authorization request and supporting documentation through the Provider Online Service Center unless they have an approved electronic claims waiver.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Covered hair-removal modalities

6 monthsMinimum diagnosis duration

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ModifiedMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Hair Removal

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Sign up for all Massachusetts Executive Office of Health and Human Services policy alerts

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Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Hair Removal

Policy CodePolicy N/A

Change TypeModified

Effective DateSep 1, 2021

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Covered hair-removal modalities

6 monthsMinimum diagnosis duration

18+Minimum member age

RequiredPrior authorization

Case by caseOther-diagnosis review

Medical Necessity and Noncoverage

Hair removal for gender dysphoria

Hair removal on any part of the body as part of treatment for gender dysphoria may be considered medically necessary when all of the following criteria are met and documented.

All gender-dysphoria criteria

Documented gender-dysphoria diagnosis: The member has been assessed by a licensed qualified behavioral health professional, resulting in a diagnosis of gender dysphoria meeting DSM-5 criteria; the diagnosis must have been present for at least six months.Diagnosis present >= 6 months
The provider must be licensed by the relevant Massachusetts licensing board or practice under the supervision of an independently licensed behavioral health professional.
Qualified professional recommendation: A licensed qualified health professional recommends hair removal for the member.
Performing-clinician medical-necessity letter: The clinician performing the hair removal provides a letter that attests to the medical necessity of hair removal and summarizes the member's care as it relates to gender-dysphoria treatment.
Minimum age: The member is 18 years of age or older.Age >= 18 years
Managed co-occurring conditions: Co-occurring medical or behavioral health disorders are appropriately managed and reasonably controlled.

Hair removal for additional diagnoses

Hair removal as a treatment for diagnoses other than gender dysphoria may be considered based on documented medical necessity.

Other-diagnosis medical necessity: The request is evaluated on a case-by-case basis and must be supported by documented medical necessity for the additional diagnosis.

Coverage is not automatic and depends on the clinical documentation submitted for the individual request.

Cosmetic hair removal is not considered medically necessary by MassHealth.

Hair removal without a diagnosis of gender dysphoria is not considered medically necessary.

Cosmetic hair removal is not considered medically necessary.

Hair removal without a diagnosis of gender dysphoria is not considered medically necessary.

Prior Authorization and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization (PA) is required for hair removal. MassHealth reviews PA requests for medical necessity; approval remains subject to all general MassHealth conditions, including member eligibility, other insurance, and program restrictions.

Documentation Required

Submit PA Through POSC

Electronically submit the PA request and all supporting documentation through the Provider Online Service Center (POSC), unless the provider has a currently approved electronic claims waiver. Waiver providers must submit the MassHealth PA-1 Form with all supporting documentation.

POSC access questions: MassHealth Customer Service Center at (800) 841-2900; TDD/TTY: 711.
PA-1 Form: https://www.mass.gov/how-to/request-priorauthorization-for-nonpharmacy-services

Clinical Context

Hair removal may be part of a multidisciplinary treatment plan for gender dysphoria and may help align physical characteristics with a member’s gender identity. The policy describes laser hair removal and electrolysis as covered modalities under the guidelines, with individualized review based on the person’s overall gendered appearance and the relative risks and benefits of treatment.

Key Terms and Modalities

Gender dysphoria

DefinitionClinically significant distress experienced due to discordance between gender identity and assigned gender.

Laser hair removal

DefinitionA hair-removal method that uses light to target individual hairs. The laser’s wavelength, energy, and pulse duration can be adjusted to target melanin in the hair follicles while leaving the surrounding skin unaffected.

Electrolysis

DefinitionThe only recognized form of permanent hair removal. A needle epilator places a thin probe in the hair follicle and delivers shortwave radio frequency to damage the follicle, prevent growth, and cause existing hair strands to fall out.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Hair Removal

Policy CodePolicy N/A

Change TypeModified

Effective DateSep 1, 2021

Next Review DateN/A

SourceLink

On This Page

Documentation Required

Assessment and Comorbidity Documentation

Include the assessment performed by the qualified licensed health professional, with the date of onset, history supporting the relevant diagnosis, and referrals for the specific procedures. Document that coexisting medical or behavioral health diagnoses are appropriately managed and reasonably controlled.

Documentation Required

Performing-Clinician Attestation and Consent

The clinician performing hair removal must provide a letter attesting that the member meets the clinical coverage criteria and summarizing the member’s care as it relates to gender dysphoria. The clinician must also document collaboration with involved health professionals, discussion of procedure risks and complications—including the clinician’s own complication rates—and informed consent from the member.

Collaboration must include, as applicable, the member’s primary care clinician and behavioral health provider.

Prior Authorization

Submitting Clinician

The clinician performing the hair-removal procedure must submit the PA request and all clinical information supporting medical necessity.

Denial Risk

All Gender-Dysphoria Criteria Must Be Met

Hair removal for gender dysphoria may be considered medically necessary only when all required criteria are met and documented. Missing any criterion or required supporting documentation creates a denial risk.

Diagnosis of gender dysphoria meeting DSM-5 criteria, assessed by a qualified licensed behavioral health professional and present for at least six months.
A licensed qualified health professional recommends hair removal.
The performing clinician provides the required medical-necessity attestation and care summary.
The member is 18 years of age or older.
Co-occurring medical or behavioral health disorders are appropriately managed and reasonably controlled.

Denial Risk

Cosmetic or Unsupported Treatment

MassHealth does not consider hair removal medically necessary when it is performed for cosmetic purposes or without a diagnosis of gender dysphoria. Such requests are not covered under these medical-necessity guidelines and may be denied.

Medical necessity for hair removal related to other diagnoses is evaluated on a case-by-case basis.

Denial Risk

Do Not Omit PA Documentation

A request that requires PA may be denied or not processed when the required authorization request and supporting clinical documentation are missing. Submit the complete request through POSC, or use the PA-1 Form and all supporting documentation only when covered by an approved electronic claims waiver.