When a beneﬁt for gender reassignment surgery exists, it is considered a covered service when the documentation submitted conﬁrms that all of the following eligibility criteria are met:
- The individual is at least 18 years of age, AND
- The individual has been diagnosed with the gender dysphoria based on the current edition of the Diagnostic and Statistical Manual of Mental Disorders, AND
- The individual initially 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
- In addition to living and working with the desired gender role full-time for a minimum of 12 months, a minimum of an additional 12 continuous months of hormone replacement therapy must occur, AND
- After the minimum of 24 continuous months of living and working within the desired gender role full-time and hormone replacement therapy, the individual should undergo repeat comprehensive independent behavioral health evaluation.
- Regular psychotherapy and counseling should be available through the member's individualized gender reassignment pathway.
When a covered beneﬁt for gender reassignment surgery exists and all of the above eligibility criteria are met, the following surgeries are Medically Necessary for transwomen (male to female):
Breast Augmentation (19324-19325) Note: augmentation mammoplasty (including breast prosthesis if necessary) if the physician prescribing hormones and the surgeon have documented that breast enlargement after undergoing hormone treatment for 12 months is not sufficient for comfort in the social role
Trachea shave/reduction thyroid chondroplasty: reduction of the thyroid cartilage (31899)