Asuris

Policy Number
153
Policy Issued In
Washington
Last Update
Breast Reconstruction

When the criteria in II.A. above are met or have been met, the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the particular requested procedure would improve otherwise documented significant gender dysphoria: 1. Breast augmentation ... 5. Mastopexy

The WPATH guideline recommends MTF patients undergo feminizing hormone therapy for a minimum of 12 months prior to augmentation surgery and lists specific criteria for breast augmentation (implants/lipofilling).

Permanent Hair Removal

When the criteria in II.A. above are met or have been met, the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the particular requested procedure would improve otherwise documented significant gender dysphoria: ... 2. Hair removal

Facial Reconstruction

When the criteria in II.A. above are met or have been met, the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the particular requested procedure would improve otherwise documented significant gender dysphoria: ... 3. Hair transplantation

Youth Services

Age at least 18 years (Note: age requirement will not be applied to mastectomy in Female-to-Male patients with documented provider determination of medical necessity of earlier intervention)

No age restriction on hormones, GnRH treatment recommended under Endocrine Society guidelines.