This specific criteria applies to mastectomies for Female to Male, breast augmentations for Male to Female, and all genital surgeries. Fallon Health may authorize the coverage of transgender surgery procedures when all of the following criteria are met, the request must be supported by the treating provider(s) medical records:
- The member is 18 years of age or older;
- Has a definitive diagnosis of persistent Gender Dysphoria that has been made and documented by a qualified licensed mental health professional such as a licensed psychiatrist, psychologist or other licensed physician experienced in the field. Fallon Health reserves the right to request the credentials of this mental health professional.
- The member has received continuous hormone therapy for 12 months or more under the supervision of a physician with documentation of the member’s compliance and the type, frequency, and route of administration;
- The member has lived as their chosen or reassigned gender full-time for 12 months or more; (3 and 4 may occur concurrently)
- For gender reassignment surgery, the member’s medical and mental health providers document that there are no contraindications to the planned surgery and agree with the plan.
There are various other procedures commonly associated with Transgender Surgery. Fallon Health recognizes these procedures bring patients into a wide range of accepted appearances of their desired gender. While Fallon Health maintains a Cosmetic Surgery Clinical Coverage Criteria policy that applies to these procedures consideration will be given to how the procedure will affect gender identity.
Puberty Suppression Hormone Therapy:
Adolescents with gender non-conformity or diagnosed gender dysphoria often begin hormone therapy at the onset of puberty. Given puberty suppression is reversible it allows an adolescent the ability to fully explore their gender non-conformity and make informed decisions regarding future treatment. Puberty Suppression hormone treatments are overseen by a Pediatric Endocrinologist and often a Mental Health professional.
In accordance with WPATH the below minimal criteria must be met
1. The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed);
2. Gender dysphoria emerged or worsened with the onset of puberty;
3. Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment;
4. The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.