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    v1.0.28
    OpenPayerPolicy UpdatesGender-Affirming CareMassHealth Gender-Affirming Surgery Coverage | Ope…
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    CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

    Guidelines for Medical Necessity Determination for Gender-Affirming Surgery

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    Clinical criteria and documentation MassHealth uses to determine medical necessity for covered masculinizing, feminizing, and facial gender-affirming surgery through prior authorization.

    Policy Summary
    PayerMassachusetts Executive Office of Health and Human Services
    PolicyGuidelines for Medical Necessity Determination for Gender-Affirming Surgery
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJun 18, 2024
    Next Review DateN/A
    Key ActionThe surgeon performing the gender-affirming surgery must submit the prior authorization request and all supporting clinical information.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    RequiredPrior authorization for gender-affirming surgery
    18+Minimum member age for specified surgeries
    6 monthsRequired diagnosis duration for specified procedures
    6 monthsSupervised hormone therapy for specified procedures

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    15
    Procedures presumed not medically necessary

    Covered Gender-Affirming Surgery Criteria

    Masculinizing chest surgery

    Covered when ALL criteria are met and documented.

    Chest masculinization

    • Clinical requirements

      • Gender dysphoria diagnosis: Assessment by a licensed qualified behavioral health professional results in a DSM-5 gender dysphoria diagnosis present for at least six months.Diagnosis present >= 6 months
      • Comorbid conditions: Comorbid medical or behavioral health conditions are appropriately managed, reasonably controlled, and are not causing symptoms of gender dysphoria.

    Masculinizing genital and related surgery

    Covered when ALL criteria are met and documented.

    Masculinizing genital and related procedures

    • Two professional assessments: Two licensed health professionals assess the member; one must be a licensed qualified behavioral health professional and the other a clinician familiar with the member's health. Each assessment results in a DSM-5 gender dysphoria diagnosis, and the initial diagnosis from one professional has been present for at least six months.Initial diagnosis >= 6 months
    • Age: The member is 18 years of age or older.>= 18 years
    • Comorbid conditions: Comorbid medical or behavioral health conditions are appropriately managed, reasonably controlled, and are not causing symptoms of gender dysphoria.
    • Hormone therapy: The member has had six continuous months of clinician-supervised hormone therapy appropriate to the member's gender goals, unless hormone therapy is medically contraindicated.

    Feminizing breast surgery

    Covered when ALL criteria are met and documented.

    Breast augmentation or mastopexy

    • Behavioral health assessment: A licensed qualified behavioral health professional assesses the member and diagnoses DSM-5 gender dysphoria present for at least six months.Diagnosis present >= 6 months
    • Age: The member is 18 years of age or older.>= 18 years
    • Comorbid conditions: Comorbid medical or behavioral health conditions are appropriately managed, reasonably controlled, and are not causing symptoms of gender dysphoria.

    Feminizing genital and related surgery

    Covered when ALL criteria are met and documented.

    Feminizing genital and related procedures

    • Two professional assessments: Two independently licensed health professionals assess the member; one must be a licensed qualified behavioral health professional and the other a clinician familiar with the member's health. Each assessment results in a DSM-5 gender dysphoria diagnosis, and the initial diagnosis from one professional has been present for at least six months.Initial diagnosis >= 6 months
    • Age: The member is 18 years of age or older.>= 18 years
    • Comorbid conditions: Comorbid medical or behavioral health conditions are appropriately managed, reasonably controlled, and are not causing symptoms of gender dysphoria.

    Facial gender-affirming surgery

    Covered when ALL criteria are met and documented.

    Facial feminization or masculinization

    • Behavioral health assessment: A licensed qualified behavioral health professional assesses the member and diagnoses DSM-5 gender dysphoria present for at least six months.Diagnosis present >= 6 months
    • Age: The member is 18 years of age or older.>= 18 years
    • Comorbid conditions: Comorbid medical or behavioral health conditions are appropriately managed, reasonably controlled, and are not causing symptoms of gender dysphoria.

    MassHealth presumes the following procedures and surgeries are not medically necessary for treatment of gender dysphoria: chemical peels; collagen injections; dermabrasion; hair transplantation; calf, gluteal, or pectoral implants; isolated blepharoplasty; lip reduction or enhancement; neck lift; panniculectomy or abdominoplasty; reversal of previous gender-affirming surgery; revisions of previous gender-affirming surgery other than for complications such as infections or impairment of function; rhytidectomy; and vocal cord surgery. This list includes examples and is not exhaustive.

    The listed procedures are presumed not medically necessary for treatment of gender dysphoria. This is a presumption under the policy and remains subject to the specific policy language and any separate applicable MassHealth guideline.

    Prior Authorization and Documentation Requirements

    Prior Authorization

    Prior Authorization Required for All GAS

    MassHealth requires prior authorization (PA) for all gender-affirming surgery (GAS) requests. PA approval does not independently guarantee payment; payment remains subject to member eligibility, other insurance, and all applicable MassHealth program requirements.

    Prior Authorization

    Operating Surgeon Must Submit the Request

    The surgeon performing the procedure must submit the PA request and all clinical documentation supporting medical necessity.

    • Include the qualified licensed health professional assessments, diagnosis history, surgery referrals, and other required supporting records.
    Documentation Required

    Clinical Background

    Gender dysphoria is clinically significant distress related to discordance between a person’s gender identity and assigned gender. Gender-affirming surgery may be one component of a multidisciplinary treatment plan involving medical, surgical, and behavioral health interventions intended to align physical characteristics with gender identity. MassHealth evaluates medical necessity individually, considering the totality of the person’s gendered appearance, procedure risks and benefits, and postoperative recovery.

    Key Definitions

    Sex
    DefinitionA biological construct based on chromosomes and anatomy.
    Gender
    DefinitionA social construct referring to attitudes, feelings, and behaviors often associated with a person’s assigned gender.
    Gender identity
    DefinitionAn individual’s personal sense of self and gender.
    Gender dysphoria
    Definition
    Policy Summary
    PayerMassachusetts Executive Office of Health and Human Services
    PolicyGuidelines for Medical Necessity Determination for Gender-Affirming Surgery
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJun 18, 2024
    Next Review DateN/A
    Key ActionThe surgeon performing the gender-affirming surgery must submit the prior authorization request and all supporting clinical information.
    SourceLink
    On This Page
    Covered Gender-Affirming Surgery CriteriaPrior Authorization and Documentation RequirementsClinical BackgroundKey Definitions
    6 continuous months

    Exception when medically contraindicated.

    Hormone therapy and breast development: The member has had six months of clinician-supervised hormone therapy resulting in no or minimal breast development, unless hormone therapy is medically contraindicated.6 months

    Exception when medically contraindicated.

  1. Hormone therapy: The member has had six continuous months of clinician-supervised hormone therapy appropriate to the member's gender goals, unless hormone therapy is medically contraindicated.6 continuous months

    Exception when medically contraindicated.

    2. Hormone Therapy May Be a Prerequisite

    For procedures with a hormone-therapy criterion, document the required period of clinician-supervised hormone therapy appropriate to the member’s gender goals, unless hormone therapy is medically contraindicated.

    • Specified masculinizing procedures: six continuous months of clinician-supervised hormone therapy.
    • Specified feminizing procedures: six months of clinician-supervised hormone therapy; augmentation mammoplasty requires no or minimal breast development after hormone therapy.
    • Document the applicable exception when hormone therapy is medically contraindicated.

    Unsupported block type: documentation

    Documentation Required

    Independent Clinician Referral Required

    For applicable procedures described in the clinical guidelines, obtain a referral from an independently qualified licensed health professional who is familiar with the member’s health and has independently assessed the member, with the assessment resulting in a DSM-5 diagnosis of gender dysphoria.

    • The referral must be provided as a letter and describe the clinical rationale for the requested surgery.
    • The referral should attest that the member was independently evaluated by a licensed qualified behavioral health professional.
    Documentation Required

    Document Comorbidity Management

    Document that coexisting behavioral health and medical conditions are appropriately managed, reasonably controlled, and not causing symptoms of gender dysphoria.

    • Include this documentation whenever required by the applicable procedure-specific clinical criteria.
    Documentation Required

    Submit Hormone Therapy Records

    When hormone therapy is a required criterion, submit medical records documenting compliance with the prescribed regimen and the member’s clinical response over the course of therapy.

    • Include records sufficient to establish the applicable duration of therapy and clinical response.
    • Document medical contraindication when the applicable guideline permits an exception.
    Documentation Required

    Surgeon Assessment and Attestations

    The operating surgeon must submit a complete clinical assessment supporting the requested GAS procedure and attest to the required clinical and care-coordination elements.

    • Include a physical examination, description of the procedure or procedures to be performed, and frontal and lateral photographs for facial surgery.
    • Attest that the member meets the applicable Section II.A clinical criteria.
    • Attest that the surgeon collaborated with the qualified licensed health professionals and other involved clinicians, including primary care and the hormone-therapy provider when applicable.
    • Document discussion of surgical risks and complications, including the surgeon’s complication rates, and obtain informed consent.
    Documentation Required

    Fertility and Sterilization Documentation

    Before surgery, document the discussion of fertility preservation and submit applicable sterilization documentation.

    • Document that the member understands fertility-preservation procedures are not covered by MassHealth.
    • Any surgery resulting in sterilization must comply with applicable state and federal laws, regulations, and guidance.
    • Submit the sterilization consent form when applicable, including HI-1, CS-18, or CS-21 as appropriate.
    Billing Rule

    Submit Electronically Through POSC

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

    • Providers using an approved waiver must submit the MassHealth PA-1 Form with all supporting documentation.
    • All clinical information must still be submitted by the surgeon performing the GAS.
    Denial Risk

    Procedures Presumed Not Medically Necessary

    MassHealth presumes that certain procedures and surgeries are not medically necessary for treatment of gender dysphoria and therefore may be noncovered.

    • Chemical peels; collagen injections; dermabrasion; hair transplantation.
    • Calf, gluteal, or pectoral implants; isolated blepharoplasty; lip reduction or enhancement; neck lift.
    • Panniculectomy or abdominoplasty; reversal of previous GAS; revisions of previous GAS other than for complications such as infection or impairment of function.
    • Rhytidectomy and vocal cord surgery.
    Denial Risk

    Failure to Meet Clinical Criteria Risks Denial

    A request may be denied when the applicable procedure-specific clinical criteria are not met or are not adequately documented.

    • Criteria may include a DSM-5 diagnosis of gender dysphoria with the required duration, assessment by the required qualified professionals, and age 18 or older where specified.
    • For applicable procedures, document the required period of clinician-supervised hormone therapy unless medically contraindicated.
    • Document that coexisting behavioral health and medical conditions are managed and reasonably controlled.
    • Ensure the requested procedure is one of the procedures identified as potentially medically necessary under the applicable clinical guideline.
    Denial Risk

    Incomplete Documentation Risks Denial or Delay

    Requests may be denied or delayed when required clinical, referral, surgeon, consent, or other supporting documentation is missing or incomplete.

    • Include qualified clinician assessments, diagnosis onset and history, procedure-specific referrals, and WPATH-recommended referral content.
    • Include independent clinician referral documentation, comorbidity-management records, and hormone-therapy compliance and response records when applicable.
    • Include the surgeon’s assessment, physical examination, procedure description, required facial-surgery photographs, clinical-criteria and collaboration attestations, risk discussion, and informed consent.
    • Include fertility-preservation and sterilization documentation when applicable, and submit all records through the required submission method.
    Clinically significant distress experienced due to discordance between gender identity and assigned gender.
    Gender-affirming surgery
    DefinitionOne or more reconstruction procedures that may be part of a multidisciplinary treatment plan involving medical, surgical, and behavioral health interventions for gender dysphoria.