26. Gender Dysphoria: Benefits for the treatment of Gender Dysphoria include only the following treatments if those treatments are determined to be Medically Necessary and appropriate for an individual: • Psychotherapy for Gender Dysphoria and associated co-morbid psychiatric diagnoses • Cross-sex hormone therapy: ➢ Cross-sex hormone therapy administered by a medical provider (for example, during an office visit) ➢ Cross-sex hormone therapy dispensed from a pharmacy • Puberty-suppressing medication injected or implanted by a medical provider in a clinical setting • Laboratory testing to monitor the safety of continuous cross-sex hormone therapy • Surgery for the treatment of Gender Dysphoria, including the surgeries listed below: Male to Female: ➢ Breast augmentation ➢ Thyroid cartilage reduction, reduction thyroid chondroplasty, or trachea shave (removal or reduction of the Adam’s apple) ➢ Voice lessons and voice therapy Female to Male: ➢ Voice lessons and voice therapy ➢ Voice modification surgery Coverage does not include procedures that are cosmetic as stated in the General Exclusions section of this SPD. Cosmetic procedures include, but are not limited to, the following: • Abdominoplasty • Bilateral mastectomy or breast reduction • Blepharoplasty • Body contouring, such as lipoplasty • Brow lift • Calf implants • Cheek, chin, and nose implants • Clitoroplasty (creation of clitoris) • Face lift, forehead lift, or neck tightening • Facial bone remodeling for facial feminizations • Hair removal • Hair transplantation • Hysterectomy (removal of uterus) • Injection of fillers or neurotoxins • Labiaplasty (creation of labia) • Laser or electrolysis hair removal in advance of genital reconstruction • Laser or electrolysis hair removal not related to genital reconstruction • Lip augmentation • Lip reduction • Liposuction • Mastopexy • Metoidioplasty (creation of penis, using clitoris) • Orchiectomy (removal of testicles) • Pectoral implants for chest masculinization • Penectomy (removal of penis) • Penile prosthesis • Phalloplasty (creation of penis) • Rhinoplasty • Salpingo-oophorectomy (removal of fallopian tubes and ovaries) • Scrotoplasty (creation of scrotum) -60- 7670-00-413597