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Breast Reconstruction

Surgical treatment of gender dysphoria may be considered medically necessary when all of the criteria listed below are met:

  • The individual is 18 years of age or older.
  • The individual has capacity to make a fully informed decision and to consent for treatment.
  • The individual is diagnosed as having a gender identity disorder (GID), including a diagnosis of transsexualism that includes ALL of the following criteria:
    • The individual has demonstrated the desire to live and be accepted as a member of the opposite sex, in addition to, a desire to make his/her body as consistent as possible with the preferred sex utilizing surgery and hormone replacement.

    • GID has been present continuously for at least two years.

    • There is no genetic or psychiatric condition present that would account for the condition.

    • GID causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • The individual is actively engaged in a recognized gender identity treatment program which includes

(1) Any underlying co-existing medical conditions are documented to be well-controlled.

(2) The covered person must complete 12 months of successful continuous full time real life experience in the desired gender without returning to the original gender.

(3) The recommendation by a mental health professional and provider under the supervision of a physician for initiation of hormonal therapy or breast surgery with a written referral to the physician who will be managing the medical treatment.

(4) Two referrals from qualified mental health professionals who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. The letter(s) must have been signed within 12 months of the request submission.

(5) The individual has undergone evaluation by the physician performing the genital surgery.

(6) The individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician.

Photographs that demonstrate breasts are outside the normal size for the normal adult female spectrum are necessary for breast augmentation.