Amerigroup

Policy Number
CG-DRUG-61
Last Update
Youth Services

Gender Dysphoria in Adolescents

Medically Necessary:

  1. GnRH analogs are considered medically necessary for adolescents with gender dysphoria when all of the following criteria are met:
    1. Fulfills the DSM V criteria for gender dysphoria; and
    2. Has experienced puberty to at least Tanner stage 2; and
    3. Has (early) pubertal changes that have resulted in an increase of their gender dysphoria; and
    4. Does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment; and
    5. Has psychological and social support during treatment; and
    6. Demonstrates knowledge and understanding of the expected outcomes of GnRH analog treatment.

Not Medically Necessary:

GnRH analogs are considered not medically necessary for adolescents with gender dysphoria when the criteria above are not met.