The Plan will review all requests for breast augmentation for male-to-female (MtF) members and mastectomy for female-to-male (FtM) members for gender affirmation using the medical criteria included in this Plan medical policy (rather than other Plan medical policies related to the requested breast procedures). Breast reconstruction for MtF members with persistent, well-documented gender dysphoria includes augmentation mammoplasty with implantation of breast prostheses and/or the medically necessary surgical removal of breast implants with replacement of breast implants after implant explantation.
Augmentation mammoplasty with implantation of breast prostheses (chest reconstruction) is considered medically necessary for male-to-female members with persistent, well-documented gender dysphoria when ALL of the following criteria are met for the initial breast augmentation for gender affirmation surgery, as specified below in items (a) through (d):
(a) The treating surgeon has reviewed the written initial assessment by a qualified licensed mental health professional (as defined in the Definitions section of this policy), and the treating surgeon has determined that the diagnosis of gender dysphoria is persistent, well-documented, and meets applicable DSM 5 criteria; AND
(b) The treating surgeon has determined that the member has the capacity to make a fully-informed decision and has the capacity to consent for treatment (including parental or guardian consent, as applicable, if the member is younger than age 18 on the date of service or informed consent is obtained from an emancipated minor according to state requirements); AND
(c) If significant medical and/or mental health concerns are present, the treating surgeon has determined that the conditions are being optimally managed and are reasonably well controlled; AND
(d) The member has had 24 continuous months of physician-supervised hormone therapy, but the treating provider has determined that the therapy has not resulted in sufficient breast development (unless hormone therapy is medically contraindicated for the member, and then this criterion is NOT applicable for the member).
Electrolysis and/or laser ablation treatments for hair removal performed by a licensed and qualified treating provider may be considered medically necessary when it is part of the standard pre-operative preparation for genital affirming genital reconstruction/affirmation surgery(ies). Examples include perineal hair removal prior to vaginoplasty and the removal of hair on a skin graft for its use in gender affirming genital reconstruction surgery but must be approved by a Plan Medical Director (e.g., hair removal on skin graft donor site prior to its use for vaginoplasty with MtF members or hair removal on skin graft donor site prior to its use for phalloplasty for FtM members). Plan prior authorization is required to determine the medical necessity of hair removal (by verifying indication for hair removal) and to coordinate coverage for the member (since hair removal is generally considered cosmetic for other indications).
Feminizing/masculinizing hormonal therapy and/or gender affirmation surgeries may limit the member’s fertility. Plan medical criteria for infertility services (covered for some Plan products) are listed in the Plan’s Infertility Services medical policy, policy number OCA 3.725; this medical policy and the member’s applicable benefit documents are available at for BMC HealthNet Plan members.
Note: Plan Medical Director review is required for any gender affirmation surgery for a member less than age 18 on the date of service. Requests for surgical treatment will be reviewed based on the Plan’s Medically Necessary medical policy, policy number OCA 3.14, and the current version of the WPATH Standards of Care for Health and Transsexual, Transgender, and Gender-Nonconforming People. In addition, the Plan Medical Director will review the member’s clinical situation, including but not limited to the amount of time the adolescent member has been living in the desired gender role, treatment timeframe with hormone therapy, age of the member, and the requested intervention. Adolescent members may be eligible for interventions when adolescents and their parents (or guardian) make informed decisions about treatment, and the service is a covered benefit for the Plan member. Informed consent by a parent or guardian for treatment of an adolescent member may not apply if the adolescent member is emancipated at the time the service is rendered (as determined by state requirements).