Some benefit designs for gender confirmation surgery may include benefits for pelvic and/or breast reconstruction. [no exclusion]
For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is (Note: for those candidates requesting female to male surgery see item 4. below): For candidates requesting female to male surgery only: a. When the initial requested surgery is solely a mastectomy, the treating physician may indicate that no hormonal treatment (as described in criteria 3. above) is required prior to performance of the mastectomy. In this case, the 12 month requirement for hormonal treatment will be waived only when all other criteria contained in this policy and in the member’s health benefit plan are met.
Gender confirmation surgery is rarely appropriate for patients under the age of 18. Requests for mastectomy for female to male transgender individuals age 17 or older may be considered only in exceptional circumstances on an individual consideration basis.
Criteria for Adolescents Entering Puberty
Adolescents, having reached puberty (tanner 2), and who have met eligibility and readiness criteria can be treated with GnRH analogues.
The definition of puberty is having reached Tanner stage 2/5 and/or having LH, estradiol levels or testosterone levels, within the pubertal range. These LH, estradiol and testosterone ranges are well-known and published and are broken down by biological male vs. biological female Tanner stage, and nocturnal and diurnal levels.
Adolescents are eligible for GnRH treatment, (for suppression of puberty) by these eligibility criteria: (same for adults)
- Have an established diagnosis for GID or transsexualism based on DSM V or ICD-10 criteria;
- Have experienced puberty to at least Tanner stage 2, which can be confirmed by pubertal levels of LH, estrogen or testosterone;
- Have experienced pubertal changes that resulted in an increase of their gender dysphoria;
- Do not suffer from psychiatric comorbidity (that interferes with the diagnostic work-up or treatment);
- Have adequate psychological and social support during treatment, to include having parental/guardian consent;
- Demonstrate knowledge and understanding of the expected outcomes of GnRH analogue treatment, cross-sex hormone treatment, and gender confirmation surgeries, as well as the medical and social risks and benefits of gender reassignment; and have been counseled regarding fertility options.