Blue Cross Blue Shield of North Dakota

Policy Issued In
North Dakota
Last Update
Policy Documents
Breast Reconstruction

Breast augmentation may be considered medically necessary in male-to-female members when criteria 1 and 2 above are met; AND:

A.     The member is at least 18 years of age; and

B.     Presence of persistent, well-documented gender dysphoria; and

C.      The member has the capacity to make a fully informed decision and to give consent to treatment; and

D.     If significant medical or mental health concerns are present, they must be reasonably well controlled; and

E.      Documentation of 18 months of continuous hormone therapy with appropriate follow-up (unless contraindications exist); and

F.      Documentation that the amount of native breast tissue is inadequate for comfort in the social role of the male-to-female member