Capital BlueCross

Policy Number
MP-1.144
Policy Issued In
Pennsylvania
Last Update
Breast Reconstruction

Gender reassignment surgery may be considered medically necessary when all of the following pre-procedure criteria are met:

  • The individual is 18 years of age or older. Individual consideration may be given to individuals under 18 years old wishing to undergo female to male chest surgery (e.g., mastectomy) after one year of testosterone therapy and when all other criteria are met.
  • The individual has been diagnosed with Gender Dysphoria of transsexualism which includes all of the following:
    • Desire to live as a member of the opposite sex, usually through body changes by surgery and hormone treatment.

    • The individual’s transsexual identity has been present for at least two years.

    • Gender Dysphoria causes significant distress and impairs social, occupational, and other important areas of functioning.

  • The individual participates in trans-gender counseling and meets all of the following:

    • The individual has lived with the desired gender role full time for at least twelve months without returning to the original gender.

    • Initiation of hormone therapy by a qualified health care professional with supportive documentation provided.

    • Recommendation for sex reassignment surgery by two mental health professionals with written documentation submitted to the physician performing the genital surgery. One letter should be from a psychiatrist or Ph.D. clinical psychologist and the second letter from a Master’s degree mental health professional, or both letters could be from psychiatrists or Ph.D. clinical psychologists. The mental health provider should have experience working with transgender clients. One of these letters should include a comprehensive evaluation/report that details well documented gender dysphoria. (see Appendix)

    • The individual has the capacity to make a fully informed decision and to consent for treatment.

When ALL of the above criteria are met for gender reassignment surgery, the following genital surgeries may be considered medically necessary for transwomen (male to female):

  • failure of breast growth stimulation by estrogen (progression only to a young adolescent stage of development), or
  • emergence of serious or intolerable adverse effects during estrogen administration, or
  • medical contraindication to use of estrogen, or
  • risk-benefit analysis determined that surgery is preferable to estrogen therapy.
Youth Services

Individual consideration may be given to individuals under 18 years old wishing to undergo female to male chest surgery (e.g., mastectomy) after one year of testosterone therapy and when all other criteria are met.