Asuris

Policy Number
153
Policy Issued In
Washington
Last Update
Breast Reconstruction

All of the following general criteria must be met for surgical gender affirming interventions for gender dysphoria to be considered for coverage:

A. Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); and

B. Clinical records document that the patient has the capacity to make fully informed decisions and consent for intervention, and that any other mental health condition, if present, is adequately controlled; and

C. At least 2 licensed mental health professionals have diagnosed gender dysphoria, and recommend surgical intervention (Note: only 1 mental health professional referral is required for mastectomy); and

D. Documentation of continuous hormonal therapy for at least 12 months, unless there is a documented contraindication to hormonal therapy (Notes: hormonal therapy is not required prior to mastectomy; hormonal therapy for at least 6 months is required for endometrial ablation); and

E. Twelve months of living in a role that is congruent with the patient’s identity.

Any of the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the intervention would improve otherwise documented significant gender dysphoria, and all of Criteria II.A.-E. above are met: 1. Breast augmentation ... 5. Mastopexy

Permanent Hair Removal

All of the following general criteria must be met for surgical gender affirming interventions for gender dysphoria to be considered for coverage:

A. Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); and

B. Clinical records document that the patient has the capacity to make fully informed decisions and consent for intervention, and that any other mental health condition, if present, is adequately controlled; and

C. At least 2 licensed mental health professionals have diagnosed gender dysphoria, and recommend surgical intervention (Note: only 1 mental health professional referral is required for mastectomy); and

D. Documentation of continuous hormonal therapy for at least 12 months, unless there is a documented contraindication to hormonal therapy (Notes: hormonal therapy is not required prior to mastectomy; hormonal therapy for at least 6 months is required for endometrial ablation); and

E. Twelve months of living in a role that is congruent with the patient’s identity.

Any of the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the intervention would improve otherwise documented significant gender dysphoria, and all of Criteria II.A.-E. above are met: ... 2. Hair removal

Facial Reconstruction

All of the following general criteria must be met for surgical gender affirming interventions for gender dysphoria to be considered for coverage:

A. Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); and

B. Clinical records document that the patient has the capacity to make fully informed decisions and consent for intervention, and that any other mental health condition, if present, is adequately controlled; and

C. At least 2 licensed mental health professionals have diagnosed gender dysphoria, and recommend surgical intervention (Note: only 1 mental health professional referral is required for mastectomy); and

D. Documentation of continuous hormonal therapy for at least 12 months, unless there is a documented contraindication to hormonal therapy (Notes: hormonal therapy is not required prior to mastectomy; hormonal therapy for at least 6 months is required for endometrial ablation); and

E. Twelve months of living in a role that is congruent with the patient’s identity.

Any of the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the intervention would improve otherwise documented significant gender dysphoria, and all of Criteria II.A.-E. above are met: ... 3. Hair transplantation

Youth Services

Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); and

No age restriction on hormones.