ModifiedMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Gender-Affirming Surgery

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This guideline explains the clinical criteria and documentation MassHealth uses to determine medical necessity for gender-affirming surgery, including masculinizing, feminizing, and facial procedures. It applies to MassHealth members and providers submitting prior authorization requests; approval remains subject to member eligibility, other insurance, and program restrictions.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Gender-Affirming Surgery

Policy CodePolicy N/A

Change TypeModified

Effective DateJune 18, 2024

Next Review DateN/A

Key ActionSubmit the prior authorization request and supporting clinical documentation through the Provider Online Service Center.

SourceLink

POLICY UPDATE CHANGES

Guideline revised and superseded the September 1, 2021 policy.

PA requiredPrior authorization is required for gender-affirming surgery

6 monthsMinimum duration of documented gender dysphoria diagnosis for applicable procedures

18+Minimum age for specified masculinizing, feminizing, and facial procedures

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ModifiedMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Gender-Affirming Surgery

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

Know when Massachusetts Executive Office of Health and Human Services releases new policies or updates existing guidance.

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Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Gender-Affirming Surgery

Policy CodePolicy N/A

Change TypeModified

Effective DateJune 18, 2024

Next Review DateN/A

Key ActionSubmit the prior authorization request and supporting clinical documentation through the Provider Online Service Center.

SourceLink

POLICY UPDATE CHANGES

Guideline revised and superseded the September 1, 2021 policy.

PA requiredPrior authorization is required for gender-affirming surgery

6 monthsMinimum duration of documented gender dysphoria diagnosis for applicable procedures

18+Minimum age for specified masculinizing, feminizing, and facial procedures

6 monthsRequired clinician-supervised hormone therapy for applicable procedures unless medically contraindicated

3 categoriesClinical coverage categories: masculinizing, feminizing, and facial feminization or masculinization surgery

11 examplesExamples of procedures MassHealth presumes are not medically necessary for gender dysphoria

Clinical Coverage Criteria

Masculinizing chest surgery

Bilateral mastectomy, reduction mammoplasty, and/or chest reconstruction or contouring may be medically necessary when all criteria are met and documented.

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
Assessment requirements are further described in Section III.A.1.
Co-morbid conditions: Co-morbid medical or behavioral health conditions are appropriately managed, reasonably controlled, and not causing symptoms of gender dysphoria.

Masculinizing genital and related surgery

The listed masculinizing genital, reproductive, and donor-site hair-removal procedures may be medically necessary when all criteria are met and documented.

Two-provider diagnosis: The member has been assessed by two licensed health professionals: one licensed qualified behavioral health professional and one clinician familiar with the member's health. Each assessment results in a diagnosis of gender dysphoria meeting DSM-5 criteria, and the initial diagnosis from one professional has been present for at least six months.Initial diagnosis >= 6 months
Providers must meet the licensing or supervision requirements stated in the guideline.
Age: The member is 18 years of age or older.Age >= 18 years
Co-morbid conditions: Co-morbid medical or behavioral health conditions are appropriately managed, reasonably controlled, and not causing symptoms of gender dysphoria.
Hormone therapy

Feminizing breast surgery

Augmentation mammoplasty with implantation of breast prostheses and mastopexy may be medically necessary when all criteria are met and documented.

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
Age: The member is 18 years of age or older.Age >= 18 years
Co-morbid conditions: Co-morbid medical or behavioral health conditions are appropriately managed, reasonably controlled, and not causing symptoms of gender dysphoria.

Feminizing genital and related surgery

The listed feminizing genital, reproductive, and donor-site hair-removal procedures may be medically necessary when all criteria are met and documented.

Two-provider diagnosis: The member has been assessed by two independently licensed health professionals: one licensed qualified behavioral health professional and one clinician familiar with the member's health. Each assessment results in a diagnosis of gender dysphoria meeting DSM-5 criteria, 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.Age >= 18 years
Co-morbid conditions: Co-morbid medical or behavioral health conditions are appropriately managed, reasonably controlled, and not causing symptoms of gender dysphoria.

Facial feminization or masculinization surgery

The listed facial feminization or masculinization procedures may be medically necessary when all criteria are met and documented.

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
Age: The member is 18 years of age or older.Age >= 18 years
Co-morbid conditions: Co-morbid medical or behavioral health conditions are appropriately managed, reasonably controlled, and 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 subject to the applicable excessive-skin guideline; reversal of previous gender-affirming surgery; revisions of previous gender-affirming surgery other than for infections or impairment of function; rhytidectomy; and vocal cord surgery.

The listed procedures are subject to a presumption of noncoverage because MassHealth considers them not medically necessary for treatment of gender dysphoria. The examples are not necessarily exhaustive; revisions may be considered when performed for complications such as infection or impairment of function.

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required and Surgeon-Submitted

MassHealth requires prior authorization (PA) for gender-affirming surgery (GAS). The PA request must be submitted by the surgeon performing the procedure and supported by clinical documentation establishing medical necessity.

Submit the request with the qualified licensed health professional assessment(s), diagnosis, and surgery referral(s).

Prior Authorization

Electronic PA Submission

Submit PA requests and all supporting clinical documentation electronically through the Provider Online Service Center (POSC).

Providers with a currently approved electronic claims waiver may use the waiver process described below.
For POSC access questions, contact the MassHealth Customer Service Center at (800) 841-2900; TDD/TTY: 711.

Clinical Background

Gender dysphoria is clinically significant distress resulting from discordance between a person's gender identity and assigned gender. Gender-affirming surgery may be one component of a multidisciplinary treatment plan that includes medical, surgical, and behavioral health interventions to help align physical characteristics with gender identity.

Key Definitions

Sex

DefinitionA biological construct based on chromosomes and anatomy.

ConstructBiological.

BasisChromosomes and anatomy.

Gender

DefinitionA social construct referring to attitudes, feelings, and behaviors often associated with a person's assigned gender.

ConstructSocial.

Associated characteristicsAttitudes, feelings, and behaviors often associated with a person's assigned gender.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Gender-Affirming Surgery

Policy CodePolicy N/A

Change TypeModified

Effective DateJune 18, 2024

Next Review DateN/A

Key ActionSubmit the prior authorization request and supporting clinical documentation through the Provider Online Service Center.

SourceLink

On This Page

The member has had six continuous months of clinician-supervised hormone therapy appropriate to the member's gender goals.6 continuous months

Hormone therapy is medically contraindicated.

Medical contraindication is an exception to the hormone-therapy requirement.

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

Medical contraindication is an exception to the hormone-therapy requirement.

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

Medical contraindication is an exception to the hormone-therapy requirement.

Documentation Required

Diagnostic Assessment and Medical-Necessity Documentation

Clinical documentation must support the medical necessity of the requested procedure, including a qualified assessment that results in a diagnosis of gender dysphoria meeting DSM-5 criteria and the required referral(s) for surgery.

Include the assessment copy, date of onset, and relevant history.
Include referrals for the specific procedures requested and all other WPATH-recommended referral-letter content.

Documentation Required

Required Referral Letter

For procedures described in Section II.A., include a referral letter from an independently qualified licensed health professional who is a clinician familiar with the member’s health and who independently assessed the member, with the assessment resulting in a DSM-5 gender-dysphoria diagnosis.

The referral must attest that the member was independently evaluated by a licensed qualified behavioral health professional.
The letter must describe the clinical rationale for the requested surgery.

Documentation Required

Co-morbid Condition Management

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

This documentation is required for the applicable masculinizing, feminizing, and facial surgery criteria.

Documentation Required

Hormone Therapy Records

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

Document six continuous months of clinician-supervised hormone therapy when required, unless therapy is medically contraindicated.
For augmentation mammoplasty or mastopexy, document six months of therapy resulting in no or minimal breast development, unless medically contraindicated.

Documentation Required

Surgeon Clinical Assessment

The surgeon’s submission must include a full clinical assessment, physical examination, description of the procedure(s) to be performed, and the required supporting images.

Include frontal and lateral photographs for facial surgery.
The surgeon must address the applicable clinical criteria for the requested procedure.

Documentation Required

Surgeon Attestations and Informed Consent

The surgeon must attest that the member meets the applicable Section II.A. coverage criteria and must document collaboration and informed-consent discussions.

Collaborate with the qualified licensed health professional(s) and other involved clinicians, including the primary-care clinician and hormone-therapy provider, if applicable.
Discuss the risks and complications of the proposed surgery, including the surgeon’s own complication rates.
Obtain the member’s informed consent.

Documentation Required

Fertility and Sterilization Documentation

Before surgery, discuss fertility preservation with the member and document that the member understands that fertility procedures are not covered by MassHealth.

Any surgery resulting in sterilization must comply with all applicable state and federal laws, regulations, and guidance.
Submit the sterilization consent form when applicable: Hysterectomy (HI-1) or Sterilization consent (CS-18 or CS-21).

Note

Submission Method and Waiver Exception

The surgeon performing the GAS must submit all clinical information and supporting documentation through the POSC unless the provider has a currently approved electronic claims waiver.

A provider using an approved waiver must 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-masshealthproviders.
See All Provider Bulletin 369 for waiver information.

Denial Risk

Masculinizing Criteria Not Met

A request for masculinizing surgery is at risk of denial if the applicable criteria are not all met and documented.

For bilateral mastectomy, reduction mammoplasty, or chest reconstruction/contouring: a qualified behavioral-health assessment must establish DSM-5 gender dysphoria present for at least six months, and co-morbid medical or behavioral-health conditions must be appropriately managed and reasonably controlled.
For hysterectomy, salpingo-oophorectomy, vulvectomy, vaginectomy, urethroplasty, metoidioplasty or phalloplasty, scrotoplasty with testicular prosthesis, and qualifying donor-site hair removal: two licensed health professionals must assess the member, including a qualified behavioral-health professional and a clinician familiar with the member’s health; the initial diagnosis must be present for at least six months.
The member must be 18 or older; co-morbid conditions must be appropriately managed and reasonably controlled; and six continuous months of clinician-supervised hormone therapy appropriate to the member’s goals must be documented unless medically contraindicated.

Denial Risk

Feminizing Criteria Not Met

A request for feminizing surgery is at risk of denial if the applicable criteria are not all met and documented.

For augmentation mammoplasty with breast-prosthesis implantation or mastopexy: a qualified behavioral-health assessment must establish DSM-5 gender dysphoria present for at least six months; the member must be 18 or older; co-morbid conditions must be appropriately managed and reasonably controlled; and six months of clinician-supervised hormone therapy must have resulted in no or minimal breast development unless medically contraindicated.
For penectomy, clitoroplasty, colovaginoplasty, vulvoplasty, labiaplasty, orchiectomy, and qualifying donor-site hair removal: two independently licensed health professionals must assess the member, including a qualified behavioral-health professional and a clinician familiar with the member’s health; the initial diagnosis must be present for at least six months.
For the procedures in the second group, the member must be 18 or older, co-morbid conditions must be appropriately managed and reasonably controlled, and six continuous months of clinician-supervised hormone therapy appropriate to the member’s goals must be documented unless medically contraindicated.

Denial Risk

Facial Surgery Criteria Not Met

Facial feminization or masculinization surgery is at risk of denial unless all applicable clinical criteria are met and documented.

The member must have a qualified behavioral-health assessment resulting in DSM-5 gender dysphoria present for at least six months.
The member must be 18 or older.
Co-morbid medical and behavioral-health conditions must be appropriately managed and reasonably controlled.

Denial Risk

Presumed Noncoverage

MassHealth presumes that certain procedures and surgeries are not medically necessary for treatment of gender dysphoria; requests for these services therefore carry a coverage risk.

Examples include chemical peels, collagen injections, dermabrasion, hair transplantation, calf/gluteal/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, rhytidectomy, and vocal cord surgery.
Panniculectomy or abdominoplasty is addressed under the Guidelines for Medical Necessity Determination for Excision of Excessive Skin and Subcutaneous Tissue.

Billing Rule

General Payment Conditions

PA approval does not guarantee payment. Even when MassHealth approves a GAS request, payment remains subject to all general MassHealth conditions and applicable program rules.

Payment depends on member eligibility.
Other-insurance requirements and limitations apply.
Program restrictions, service conditions, coverage limitations, and applicable regulations and provider-manual requirements continue to control payment.
Members enrolled in an ACPP, MCO, One Care, SCO, or PACE plan may be subject to that organization’s medical policies for covered services.

Gender identity

DefinitionAn individual's personal sense of self and gender.

Personal senseAn individual's personal sense of self.

Related conceptGender.

Gender dysphoria

DefinitionClinically significant distress experienced because of discordance between gender identity and assigned gender.

Diagnostic referenceThe diagnosis must meet DSM-5 criteria when required by the guideline.

Former terminologyGender dysphoria has replaced gender-identity disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Gender-affirming surgery

DefinitionOne or more reconstruction procedures that may form part of a multidisciplinary treatment plan for gender dysphoria.

Treatment-plan contextMay be part of a multidisciplinary treatment plan involving medical, surgical, and behavioral health interventions available for the treatment of gender dysphoria.

Therapeutic purposeMay be part of therapeutic treatment to better align physical characteristics with gender identity.