CareSource (Ohio Medicaid)

Policy Number
MM-0034
Policy Issued In
Ohio
Last Update
Breast Reconstruction

The following are requirements that apply for consideration of sexual reassignment surgery: (List is not meant to represent all requirements)

1. Breast/chest surgery

a. Unless contraindicated or is unable to take, individual has participated in 12 consecutive months of cross-sex hormone therapy for the desired gender.

b. Hormone trial must be with a medication prescribed to the member

d. One letter of recommendation from a QMHP to the surgeon is required

  1. QMHP has evaluated the member within the past twelve months of the time of referral
  2. If member has been in behavioral health treatment, it is preferred that the recommendation is made by the behavioral health treatment provider (if the provider is a QMHP)
  3. If there is not a treating QMHP, a letter of recommendation may be made by a consulting QMHP
  4. If the QMHP is a member of a treatment team with the surgeon, documentation in the integrated clinical record is an option in lieu of a letter
  5. Content of the QMHP referral letter must address at minimum:

(1) Duration of evaluator’s relationship with the member

(2) Member has well-documented diagnosis of gender dysphoria

(3) A member specific treatment plan

(4) Member has capacity to give informed consent for surgery

(5) Member is age 18 years or older

(6) Member has had a twelve-month or longer real-life experience congruent with their gender identity

(7) The gender dysphoria diagnosis has been consistently persistent for a duration of 6 months or longer at the time of the authorization request.

(8) If co-existing mental illness substance related disorder are present, it is relatively well controlled, there has been no active intravenous drug use for the past 3 months and no suicide attempts or behaviors in the past 6 months.

(9) QMHP communicates willingness to be available to treat the member during transition or make appropriate referral if member needs assistance with behavioral health treatment

Sexual reassignment surgery

1. All members requesting ANY of the sexual reassignment surgeries (see list below).

a. MtF

01. Breast reconstruction