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    v1.0.28
    OpenPayerPolicy UpdatesGender-Affirming CareMassHealth Hair Removal Coverage | OpenPayer
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    CurrentMassachusetts 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 prior authorization and medical-necessity review for non-presurgical hair removal, particularly laser hair removal and electrolysis, when used to treat gender dysphoria. It also addresses case-by-case review for other diagnoses and applies to providers submitting requests for MassHealth members.

    Policy Summary
    PayerMassachusetts Executive Office of Health and Human Services
    PolicyGuidelines for Medical Necessity Determination for Hair Removal
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMay 9, 2024
    Next Review DateN/A
    Key ActionThe clinician performing the hair-removal procedure must submit the prior authorization request and all supporting clinical documentation.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    RequiredPrior authorization
    18+Minimum member age
    6 months

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    Documented diagnosis duration
    2Covered hair-removal forms
    5Required clinical criteria
    ExcludedCosmetic use

    Medical Necessity Criteria

    Hair Removal as Treatment 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 of the following

    • The member has been assessed by a licensed qualified behavioral health professional, resulting in a diagnosis of gender dysphoria meeting DSM-5 criteria. This diagnosis must have been present for at least six months. Detailed information on the requirements for these assessments can be found in Section III.1.
    • A licensed qualified health professional recommends hair removal for the member. Detailed information on the requirements for these assessments can be found in Section III.1.
    • A letter from the clinician performing the hair removal includes attestation of the medical necessity of hair removal and a summary of the member’s care as it relates to gender dysphoria treatment. Detailed information on the requirements for these letters can be found in Section III.3.
    • The member is 18 years of age or older.
    • Co-occurring medical or behavioral health disorders are appropriately managed and reasonably controlled.

    Hair Removal as Treatment for Additional Diagnoses

    Hair removal as a treatment for any other diagnosis may be considered on a case-by-case basis based on documented medical necessity.

    Hair removal is being provided as treatment for a diagnosis other than gender dysphoria and is supported by documented medical necessity on a case-by-case basis.

    MassHealth does not consider hair removal to be medically necessary when it is provided for cosmetic purposes.

    MassHealth does not consider hair removal to be medically necessary when it is provided without a diagnosis of gender dysphoria.

    MassHealth does not consider hair removal to be medically necessary under certain circumstances, including but not limited to hair removal for cosmetic purposes or without a diagnosis of gender dysphoria.

    Prior Authorization and Submission Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for MassHealth-covered hair removal. MassHealth reviews each request for medical necessity; approval remains subject to member eligibility, other insurance, and all applicable program restrictions.

    Documentation Required

    Performing Clinician Must Submit

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

    • The submission must identify the performing clinician as the responsible submitting clinician.
    • All required clinical information must accompany the request.
    Prior Authorization

    Clinical Context

    Hair removal may be included in a multidisciplinary treatment plan for gender dysphoria. It may help align physical characteristics with a member’s gender identity, with medical-necessity review based on the individual’s overall gendered appearance and the relative risks and benefits of the procedure.

    Key Terms and Services

    Gender dysphoria
    Clinical meaningClinically significant distress experienced due to discordance between gender identity and assigned gender.
    DSM-5 terminologyThe term gender dysphoria replaced “gender-identity disorder” in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
    Relationship to physical characteristicsGender dysphoria may include a desire to have sex characteristics aligned with one’s gender identity rather than assigned gender.
    Laser hair removal
    MethodA hair-removal method that uses light to target individual hairs in a space of skin covered by a quarter.
    MechanismManipulating the laser’s wavelength, energy, and pulse duration targets melanin (pigment) in hair follicles while leaving the rest of the skin unaffected.
    Policy Summary
    PayerMassachusetts Executive Office of Health and Human Services
    PolicyGuidelines for Medical Necessity Determination for Hair Removal
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMay 9, 2024
    Next Review DateN/A
    Key ActionThe clinician performing the hair-removal procedure must submit the prior authorization request and all supporting clinical documentation.
    SourceLink
    On This Page
    Medical Necessity CriteriaPrior Authorization and Submission RequirementsClinical ContextKey Terms and Services

    Electronic PA Submission

    Submit the PA request and all supporting documentation electronically through the MassHealth Provider Online Service Center (POSC), unless the provider has a currently approved electronic claims waiver.

    • Questions about POSC access: MassHealth Customer Service Center, (800) 841-2900; TDD/TTY: 711.
    • See All Provider Bulletin 369 for electronic-submission waiver information.
    Documentation Required

    Behavioral Health Assessment and Referral

    Include the qualified licensed health professional’s assessment supporting the diagnosis and treatment recommendation. The documentation must include the date of onset, relevant diagnostic history, and referrals for the specific procedures.

    • The assessment must support a diagnosis of gender dysphoria meeting DSM-5 criteria.
    • The diagnosis must have been present for at least six months.
    • A licensed qualified health professional must recommend hair removal for the member.
    Documentation Required

    Manage Coexisting Conditions

    Document that any coexisting medical or behavioral health diagnoses are appropriately managed and reasonably controlled.

    • Include this documentation with the PA request and supporting clinical records.
    Documentation Required

    Medical-Necessity Letter

    The performing clinician must provide a medical-necessity letter attesting that the member meets the clinical criteria for coverage and summarizing the member’s care as it relates to gender-dysphoria treatment.

    • The letter must attest that all Section II.A clinical criteria are met.
    • The letter must include a summary of the member’s care related to gender dysphoria.
    Documentation Required

    Document Care Coordination

    The performing clinician’s letter must document collaboration with other health care professionals involved in the member’s care.

    • Include collaboration with the member’s primary care clinician, behavioral health provider, and any other involved health care professionals.

    Unsupported block type: documentation

    Billing Rule

    Use the Approved Submission Method

    Use the POSC for electronic PA submission unless the provider has a currently approved electronic claims waiver. A request submitted outside the POSC without an approved waiver may not be processed.

    • The waiver must be currently approved.
    • The waiver exception applies to the electronic submission requirement, not to the requirement for complete supporting documentation.
    Billing Rule

    Waiver Submission Requirements

    For a PA request submitted under a currently approved electronic claims waiver, include the MassHealth Prior Authorization Request (PA-1 Form) and all supporting documentation.

    • The PA-1 Form is available at mass.gov/prior-authorization-for-masshealth-providers.
    • Providers without an approved waiver must submit through POSC.
    Denial Risk

    Cosmetic or Unsupported Treatment

    Hair removal is not considered medically necessary when it is performed for cosmetic purposes or when the member does not have a diagnosis of gender dysphoria.

    • These circumstances may result in noncoverage or denial.
    Denial Risk

    Incomplete Clinical Criteria Risk

    Coverage may be denied when any required gender-dysphoria criterion is unmet or not documented. Hair removal may be considered medically necessary only when all applicable criteria are met and documented.

    • The member has a DSM-5 gender-dysphoria diagnosis established by a licensed qualified 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 letter 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

    Improper PA Submission

    Incorrect submission practices may cause denial or processing delays. The performing clinician must submit the request through POSC, unless the provider has a currently approved electronic claims waiver, and must include complete supporting documentation.

    • Requests submitted by someone other than the performing clinician do not meet the submission requirement.
    • Requests using a non-POSC method without an approved waiver must include the PA-1 Form and all supporting documentation.
    • Missing clinical documentation may prevent MassHealth from establishing medical necessity.
    RisksRisks include depigmentation, burns, scarring, and infection; the risk of depigmentation is highest in darker-skinned patients.
    Electrolysis
    MethodA hair-removal method performed with a needle epilator, not electronic tweezers.
    Equipment and placementA thin probe is placed in the hair follicle.
    MechanismA shortwave radio frequency destroys hair growth, damages hair follicles to prevent growth, and causes existing hair strands to fall out.
    Risks and complicationsElectrolysis is the only recognized form of permanent hair removal; side effects and complications are minimal and temporary, such as reddening of the skin.
    Non-presurgical hair removal
    DefinitionHair removal that is not performed as part of a surgical procedure.
    Primary policy useThe Guidelines identify clinical information needed to determine medical necessity for non-presurgical hair removal for treatment of gender dysphoria.
    Recognized methodsThe Guidelines recognize laser hair removal and electrolysis as forms of non-presurgical hair removal.