Blue Cross Blue Shield of North Dakota

Policy Issued In
North Dakota
Last Update
Breast Reconstruction

GRS may be considered medically necessary when ALL of the following are met:

  • The individual is greater than or equal to 18 years of age; and
  • The individual has the capacity to make a fully informed decision and to consent for treatment; and
  • The individual has been diagnosed with the gender dysphoria of transsexualism, including ALL of the following:
    • The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
    • The individual’s transsexual identity has been present persistently for at least two (2) years; and
    • The disorder is not a symptom of another mental disorder or a chromosomal abnormality; and
    • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The individual is an active participant in a recognized gender identity treatment program and demonstrates ALL of the following conditions:
    • The individual has successfully lived and worked within the desired gender role full-time for at least 12 months (real life experience) without returning to the original gender; and
    • For breast surgery
      • Initiation of hormonal therapy (unless medically contraindicated or individual is unable or unwilling to take hormones); and
      • One referral from a qualified mental health professional with written documentation submitted to the physician performing the breast surgery; and
    • For genital surgery
      • Documentation of at least 12 months of continuous hormonal sex reassignment therapy, (unless medically contraindicated or indivudal is unable or unwilling to take hormones) (may be simultaneous with real life experience);
      • Two referrals from qualified mental health professionals who have independently assessed the individual. If the first referral is from the individual’s psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (e.g., if practicing within the same clinic) may be sent*; and
    • Separate evaluation by the physician performing the genital surgery.

* At least one (1) letter must be a comprehensive report.

When ALL of the above criteria are met, the following breast/genital surgeries may be considered medically necessary for the following indications:

  • Breast augmentation

Although not a requirement, it is recommended that MTF undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.