Does Cigna Cover Breast Reduction Surgery – 1 Cigna Medical Coverage Policies Genital Surgery Topic Table of Contents Highlights… 1 General… 3 Marketing Information/May 2016 Coverage Policy Numbers Hyperlinks to Related Coverage Liposuction and Abdominoplasty Blepharoplasty, Reconstructive Eyelid Surgery and Brow Lift Rhinoplasty, Ventricular Stenosis Repair, and Septoplasty Excess Skin Surgery Speech Therapy Policy Cigna Company Policies Health Policy Outcomes. The Operating Principles are intended to provide guidance in the interpretation of certain Cigna benefit plans. The benefit details that clients fill out [group service agreement, certificate of coverage, certificate of coverage, summary plan description (SPD), or similar plan document] may be significantly different than the regular plan from which they receive benefits. Derived. For example, a client’s benefits document may include exclusions related to topics described in the coverage policy. In the event of a dispute, customer support documentation will always take precedence over coverage policy terms. In the absence of governmental or state regulatory approval, benefits will be determined based on the contents of your supporting documentation. To determine what occurred during each period, you will need to rely on 1) the principles of the benefit documents in effect on the date of hire; 2) relevant laws/regulations 3) integrated operational tools, including supporting policies 4) actual circumstances. Management principles relate to the management of health plans. These treatment instructions should not be used as medical guidance. In some markets, vendor-provided guidance may be used to support medical and other healthcare needs. More information about Cigna. Copyright 2015 Cigna Coverage Policies Most health plans specifically cover gender reassignment surgeries and related services (including pre- and post-hormone treatments). Additionally, gender reassignment surgery procedures performed to improve or alter one’s appearance or self-esteem associated with one’s appearance are considered cosmetic in nature and not medically necessary. Please refer to the benefit document to determine the availability of benefits and benefit requirements, conditions, and limitations. Situations where support for gender reassignment surgery is available are as follows: Cigna also covers the following gender reassignment surgeries, including pre- and post-operative care (if medically necessary), if the individual is 18 years of age or older, has a diagnosed gender identity disorder, and is enrolled in a recognized gender reassignment program . Gender reassignment breast surgery (e.g. primary mastectomy, mastectomy), which requires a request letter from a specialist, and salpingo-oophorectomy, which requires both of the following: o o Continued hormones for at least 12 months* Gender reassignment history Treatment surgery recommended Genital reconstruction (i.e. genital resection surgery) A letter from two qualified health care professionals to the doctor who performed the genital surgery and a written report must be a complete report. Two separate letters Page 1 of 12

Two letters or one letter with two signatures are acceptable. A letter from a master’s degree in psychiatry is acceptable if the second letter is from a psychiatrist or PhD. Psychiatrist) Vaginectomy (including vaginectomy, vaginoplasty, including primary phalloplasty, urethroplasty, urethroplasty) All of the following conditions have been met: o History of continuous hormone therapy for at least 12 months* Sexual intercourse (possibly Coinciding with the actual event) This is an important pose and must be male or female for at least 12 months (including work or school events). , relatives, friends, community members (e.g., schools, workplaces, etc.) who have undergone gender-affirming sex reassignment surgery (e.g., genital surgery), and two licensed psychiatrists to see the surgeon. Genital surgery (one letter must be a complete report. Two separate letters or one letter with two signatures are acceptable. One letter from a master’s degree in psychiatry, if the second letter is from a psychiatrist or psychologist PhD. Barrel allowed.) Male is a female transgender surgeon if all of the following are met: o Consultation for gender reassignment surgery (e.g., genital surgery) AND 2. (One letter must be a complete report. Two separate letters OR One letter with two signatures is acceptable provided the second letter is from a psychiatrist or PhD practicing psychologist.) Phalloplasty; penile skin reversal, vaginal introitus repair, nipple closure and implantation, colostomy), if all of the following criteria are met: o Documentation of ongoing sexual dysfunction and hormone therapy for at least 12 months* (can coincide with real-life events) Includes various life events and events (e.g., family activities , vacations, vacations, work or school events), including information about identified friends, family, friends and community members (e.g. school, work, etc.). Two qualified mental health professionals providing written advice on gender reassignment surgery (e.g. genital surgery) and genital surgery (one letter must be two separate letters or a complete report with two signatures). One letter is acceptable. One letter from a master’s degree may be accepted for a PhD in psychiatry if the second letter is from a psychiatrist or clinical psychologist PhD. ) *Note: Hysterectomy/salpingo-oophorectomy, orchiectomy, vaginectomy, or A complete course of 12 months of continuous hormonal therapy is necessary for patients being considered for vaginoplasty. Vaginectomy or vaginoplasty does not require an additional 12 months of hormonal therapy. Cigna does not cover the purchase, reservation, or storage of these items as part of the fertility-preserving relocation process because these items are not covered by many benefits and are not considered medically necessary. Embryo Sperm Page 2 of 12

Does Cigna Cover Breast Reduction Surgery

3 Oocytes Cigna does not guarantee the cryopreservation, storage or thawing of reproductive tissue (i.e. eggs, testicular tissue). Because each one is considered experimental, research or unproven. Cigna considers the following cosmetic procedures to be medically unnecessary as part of gender reassignment surgery, although there may be benefits to gender reassignment surgery (which may not be included in this list): Breast augmentation Abdominoplasty Blepharoplasty (including breast augmentation). Breast augmentation, implants, silicone injection ball implants/chin implants chin/nose implants collagen injection electrolysis facial/forehead lift forehead hair removal/hair transplant penile prosthesis (non-inflatable/inflatable) testicle expander chin Shortening/Bone Sculpting/Facial Reduction Throat Cosmetic Lip/Augmentation Liposuction Mastopexy Neck Augmentation Nipple/areola reconstruction Breast implants Muscle expanders and removal of excess skin to replace implants Permanent testicular replacement Nasal Plastic surgery Scrotoplasty Two-stage phalloplasty Skin resurfacing (eg chemical dermal hydration) Resurfacing (eg chemical dermal) Inflatable prosthesis (eg chemical dermal) Pump and/or cylinder and/or reservoir Multiple components, including testicular prosthesis) Tracheal Curettage/Thyroid Chondroplasty Term Change Surgery Term/Word Education General Background Gender reassignment therapy is a term commonly used in treatments related to gender reassignment. Transgender people (i.e., a mismatch between internal gender identity and genetic sex) and people with disorders of sexual development (DSD) (formerly known as intersex people). The term “gender reassignment surgery,” also known as gender reassignment surgery, can specifically refer to the surgical repositioning of male or female genitals or the repositioning of a male body into a female body. . , or vice versa. Gender reassignment surgery is part of a gender dysphoria treatment plan. Little is known about the causes of gender dysphoria and the developmental factors associated with it. A person whose genetic makeup is male but whose gender is female; a person who adopts female gender characteristics and roles Page 3 of 12

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4 I identify as a trans woman. People whose genetic characteristics are female but whose gender is male and who have both male and female appearances are called transgender people. Transgender, transsexual, and gender nonconforming people (i.e., whose gender identity differs from their culture) may experience gender dysphoria. Gender dysphoria is defined as discomfort or stress caused by the difference between gender and sex assigned at birth (World Professional Association for Transgender Health [WPATH], 2012). This also includes gender roles and/or primary and secondary sexual characteristics. Gender dysphoria can be relieved through a variety of treatments, some of which include gender reassignment or physical changes such as hormones and/or surgery. The term “transgender” refers to a person who self-identifies as male or female.

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