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Health Insurance Medical Policies - Breast Reconstruction / Breast Augmentation


Below are excerpts from various health insurance medical policies that have explicit provisions detailing when breast reconstruction/breast augmentation is covered for transgender women.

The fact that an insurance company is listed here does not mean that your particular plan will follow these guidelines. You must look to your individual policy to determine if transgender care is covered or excluded. Only if it is covered will the policies below apply.

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

Policy: Breast Surgeries

Breast Reconstruction Policy:

AllWays Health Partners also covers medically necessary breast reconstruction surgery in the following instances:

1. For treatment other than cancer-related mastectomy/lumpectomy (photo documentation is required) for a member with:

a. Severe disfigurement from Poland Syndrome or other disease; OR

b. Gender dysphoria when a member is transitioning from male to female and meets relevant medical necessity criteria for coverage under the Gender Reassignment Treatment and the request is for augmentation mammoplasty.

c. Severe breast asymmetry of at least 2 cup difference in breast size in a female patient who has reached full physical maturity, i.e., tanner stage V, typically age 15 and older.

Policy: Treatment of Gender Dysphoria

Breast Reconstruction Policy:

Breast augmentation is considered medically necessary and, therefore, covered, when all of the following criteria are met:

  • The individual has persistent, well-documented gender dysphoria in accordance with the criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, [DSM-5].
  • Breast augmentation is recommended by a qualified professional provider who has consistently monitored the individual up to the time of surgery.
    • One referral letter and/or chart documentation must be written from the mental health professional provider who consistently monitored the individual throughout their psychotherapy or any other evaluation to the professional provider who will be responsible for the individual's treatment.
  • The individual is at least 18 years of age.
  • The individual, unless medically contraindicated, has used feminizing hormones continuously and responsibly (which may include screenings and follow-ups with the professional provider) for a 12-month period.
  • The individual, if required by a mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider.
  • If the individual has significant medical or mental health concerns, they are reasonably well controlled.
Policy: Transgender Services

Breast Reconstruction Policy:

All of the following general criteria must be met for surgical gender affirming interventions for gender dysphoria to be considered for coverage:

A. Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); and

B. Clinical records document that the patient has the capacity to make fully informed decisions and consent for intervention, and that any other mental health condition, if present, is adequately controlled; and

C. At least 2 licensed mental health professionals have diagnosed gender dysphoria, and recommend surgical intervention (Note: only 1 mental health professional referral is required for mastectomy); and

D. Documentation of continuous hormonal therapy for at least 12 months, unless there is a documented contraindication to hormonal therapy (Notes: hormonal therapy is not required prior to mastectomy; hormonal therapy for at least 6 months is required for endometrial ablation); and

E. Twelve months of living in a role that is congruent with the patient’s identity.

Any of the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the intervention would improve otherwise documented significant gender dysphoria, and all of Criteria II.A.-E. above are met: 1. Breast augmentation ... 5. Mastopexy

Policy: Transgender Services Benefits

Breast Reconstruction Policy:

A member must meet ALL the following criteria established under the World Professional Association for Transgender Health (WPATH) (7th version) in order to be eligible:

  1. Diagnosis of Gender Identity Disorder (ICD-10 F64.0, F64.1 or F64.9); and
  2. Age of majority (18 years of age or older); and
  3. Have knowledge of the benefits and risks of surgery as demonstrated by and documented in an evaluationfrom a qualified mental health professional; and
  4. Unless medically contraindicated, completion of twelve (12) months of continuous hormone therapy (EXCEPT for Mastectomy); and
  5. Twelve continuous months of living in a congruent gender role with his/her gender identity (real life experience) prior to the gender reassignment services noted in the medical documentation (start/end dates included); and
  6. If the member has significant medical or mental health issues present, they must be reasonably well controlled and noted in the medical documentation. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy prior to surgery and the effort(s) noted in the medical documentation; and
  7. Two (2) referrals from qualified mental health professionals who have independently assessed the individual. 1 referral should be from a person who has only had an evaluative role with the individual. Both referring providers must submit letters of their evaluation. (At least 1 of the evaluating professionals must have a doctoral degree [PhD, MD, Ed.B, D. Sc, D.S.W. or Psy.D] and be capable of adequately evaluating co-morbid psychiatric conditions.)

BREAST DEVELOPMENT - female hormones for at least 12 months to achieve adequate breast development without surgery. Any further intervention by surgical means would be reviewed for medical necessity in accordance with medical policy #106 Reconstructive versus Cosmetic Surgery.

Policy: Treatments for Gender Dysphoria

Breast Reconstruction Policy:

If benefit coverage for gender dysphoria treatment is available, the following surgical procedures are considered eligible for coverage: Initial breast augmentation (implants/lipofilling) with documentation of ALL of the following:

  • One referral from qualified mental health professional
  • Persistent, well-documented gender dysphoria
  • Capacity to make a fully informed decision and to give consent for treatment
  • Age of majority in a given country (if younger, follow the SOC for children and adolescents)
  • If significant medical or mental health concerns are present, they must be reasonably well controlled

Although not an explicit criterion, feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery is recommended. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Breast Reconstruction Policy:

The individual being considered for surgery and related services must meet ALL the following criteria. The individual must have:

  • Reached the age of majority; AND
  • The capacity to make a fully informed decision and to consent for treatment; AND
  • Been diagnosed with persistent, well-documented gender dysphoria; AND
  • The required referrals prior to any surgery or related service(s):

Prior to breast/chest surgery, e.g., mastectomy, chest reconstruction, or breast augmentation, one required referral from the individual’s qualified mental health professionals (see NOTE 1 below) competent in the assessment and treatment of gender dysphoria

NOTE 1: Psychotherapy and Mental Health Services:

Psychotherapy is not required for gender reassignment services except when a mental health professional recommends psychotherapy based on initial assessment prior to gender reassignment surgery. The recommendation for psychotherapy must specify the goals of treatment along with estimates of the frequency and duration of therapy throughout the individual’s experience living in one’s affirmed gender. Review the criteria above under “Criteria for Coverage of Gender Reassignment Surgery and Related Services” for required surgical referral letters from qualified mental health professionals.

Male-to-Female (MtF) surgical procedures performed as part of gender reassignment services for an individual who has met the above criteria for gender dysphoria may be considered medically necessary and include the following:

• Breast modification, including but not limited to breast enlargement, breast augmentation, mastopexy, implant insertion, and silicone injections, and nipple or areola reconstruction

Policy: Gender Affirming Services (Transgender Services)

Breast Reconstruction Policy:

Breast augmentation for transfeminine members may be considered MEDICALLY NECESSARY when ALL of the following candidate criteria are met:

  • Age ≥ 18,
  • The candidate has been diagnosed with gender dysphoria (ICD-10 codes F64.0-F64.9 gender identity disorder), including meeting ALL of the following indications:
    • The desire to live and be accepted as a member of another gender other than one’s assigned
      sex, typically accompanied by the desire to make the physical body as congruent as possible
      with the identified gender through surgery and hormone treatment.
    • The new gender identity has been present for at least 12 months.
    • The member has a consistent, stable gender identity that is well documented by their treating
      providers, and when possible, lives as their affirmed gender in places where it is safe to do
      so.
    • The gender dysphoria (ICD-10 codes F64.0-F64.9 gender identity disorder) is not a symptom
      of another mental disorder.
  • For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is provided under the supervision of a licensed clinician.
Policy: Surgical Treatment of Gender Dysphoria

Breast Reconstruction Policy:

Breast augmentation (e.g. implants/lipofilling) may be considered MEDICALLY NECESSARY AND APPROPRIATE in male-to-female members when criteria in section I AND the following criteria are met: 

  • The member is at least 18 years of age (legal age of majority in Minnesota). Requests for breast surgery for a member younger than 18 years of age will be reviewed by medical director; and
  • Persistent, well-documented gender dysphoria; and
  • Capacity to make a fully informed decision and to give consent to treatment; and
  • If significant medical or mental health concerns are present, they must be reasonably well-controlled.
  • NOTE:  Hormone therapy is not a prerequisite for breast augmentation for male-to-female members. The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People Version 7 from the World Professional Association for Transgender Health (WPATH) state the following:  "Although not an explicit criterion, it is recommended that MtF (male-to-female) patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results."

Documentation Requirements

  • One letter of recommendation must be provided to a health plan representative from a qualified mental health professional. The letter must address ALL of the following:
    1. The member's general identifying characteristics; and
    2. Results of the member's psychosocial assessment, including any diagnoses; and
    3. The duration of the mental health professional's relationship with the member including the type of evaluation and therapy or counseling to date; and
    4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the member's request for surgery; and
    5. A statement about the fact that informed consent has been obtained from the patient; and
    6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.
  • The health plan and the physician responsible for breast removal or augmentation must receive this letter and recommendations for surgery and the surgical treatment must be authorized by the health plan prior to its occurrence. If the providers are working within a multidisciplinary specialty team, the letters may be sent only to the health plan with documentation of the information in the member's chart.
Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Breast Reconstruction Policy:

The individual being considered for surgery and related services must meet ALL the following criteria. The individual must have:

  • Reached the age of majority; AND
  • The capacity to make a fully informed decision and to consent for treatment; AND
  • Been diagnosed with persistent, well-documented gender dysphoria; AND
  • The required referrals prior to any surgery or related service(s):

o Prior to breast/chest surgery, e.g., mastectomy, chest reconstruction, or breast augmentation, one required referral from the individual’s qualified mental health professionals (see NOTE 1 below) competent in the assessment and treatment of gender dysphoria

NOTE 1: Psychotherapy and Mental Health Services:

Psychotherapy is not required for gender reassignment services except when a mental health professional recommends psychotherapy based on initial assessment prior to gender reassignment surgery. The recommendation for psychotherapy must specify the goals of treatment along with estimates of the frequency and duration of therapy throughout the individual’s experience living in one’s affirmed gender. Review the criteria above under “Criteria for Coverage of Gender Reassignment Surgery and Related Services” for required surgical referral letters from qualified mental health professionals.

Male-to-Female (MtF) surgical procedures performed as part of gender reassignment services for an individual who has met the above criteria for gender dysphoria may be considered medically necessary and include the following:

• Breast modification, including but not limited to breast enlargement, breast augmentation, mastopexy, implant insertion, and silicone injections, and nipple or areola reconstruction

Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Breast Reconstruction Policy:

The individual being considered for surgery and related services must meet ALL the following criteria. The individual must have:

  • Reached the age of majority; AND
  • The capacity to make a fully informed decision and to consent for treatment; AND
  • Been diagnosed with persistent, well-documented gender dysphoria; AND
  • The required referrals prior to any surgery or related service(s):

o Prior to breast/chest surgery, e.g., mastectomy, chest reconstruction, or breast augmentation, one required referral from the individual’s qualified mental health professionals (see NOTE 1 below) competent in the assessment and treatment of gender dysphoria

NOTE 1: Psychotherapy and Mental Health Services:

Psychotherapy is not required for gender reassignment services except when a mental health professional recommends psychotherapy based on initial assessment prior to gender reassignment surgery. The recommendation for psychotherapy must specify the goals of treatment along with estimates of the frequency and duration of therapy throughout the individual’s experience living in one’s affirmed gender. Review the criteria above under “Criteria for Coverage of Gender Reassignment Surgery and Related Services” for required surgical referral letters from qualified mental health professionals.

Male-to-Female (MtF) surgical procedures performed as part of gender reassignment services for an individual who has met the above criteria for gender dysphoria may be considered medically necessary and include the following:

• Breast modification, including but not limited to breast enlargement, breast augmentation, mastopexy, implant insertion, and silicone injections, and nipple or areola reconstruction

Policy: Gender Confirmation Surgery and Hormone Therapy

Breast Reconstruction Policy:

Some benefit designs for gender confirmation surgery may include benefits for pelvic and/or breast reconstruction. [no exclusion]

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

GRS may be considered medically necessary when ALL of the following are met:

  • The individual is greater than or equal to 18 years of age; and
  • The individual has the capacity to make a fully informed decision and to consent for treatment; and
  • The individual has been diagnosed with the gender dysphoria of transsexualism, including ALL of the following:
    • The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
    • The individual’s transsexual identity has been present persistently for at least two (2) years; and
    • The disorder is not a symptom of another mental disorder or a chromosomal abnormality; and
    • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The individual is an active participant in a recognized gender identity treatment program and demonstrates ALL of the following conditions:
    • The individual has successfully lived and worked within the desired gender role full-time for at least 12 months (real life experience) without returning to the original gender; and
    • For breast surgery
      • Initiation of hormonal therapy (unless medically contraindicated or individual is unable or unwilling to take hormones); and
      • One referral from a qualified mental health professional with written documentation submitted to the physician performing the breast surgery; and
    • For genital surgery
      • Documentation of at least 12 months of continuous hormonal sex reassignment therapy, (unless medically contraindicated or indivudal is unable or unwilling to take hormones) (may be simultaneous with real life experience);
      • 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 (e.g., if practicing within the same clinic) may be sent*; and
    • Separate evaluation by the physician performing the genital surgery.

* At least one (1) letter must be a comprehensive report.

When ALL of the above criteria are met, the following breast/genital surgeries may be considered medically necessary for the following indications:

  • Breast augmentation

Although not a requirement, it is recommended that MTF undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Breast Reconstruction Policy:

The individual being considered for surgery and related services must meet ALL the following criteria. The individual must have:

  • Reached the age of majority; AND
  • The capacity to make a fully informed decision and to consent for treatment; AND
  • Been diagnosed with persistent, well-documented gender dysphoria; AND
  • The required referrals prior to any surgery or related service(s):

o Prior to breast/chest surgery, e.g., mastectomy, chest reconstruction, or breast augmentation, one required referral from the individual’s qualified mental health professionals (see NOTE 1 below) competent in the assessment and treatment of gender dysphoria

NOTE 1: Psychotherapy and Mental Health Services:

Psychotherapy is not required for gender reassignment services except when a mental health professional recommends psychotherapy based on initial assessment prior to gender reassignment surgery. The recommendation for psychotherapy must specify the goals of treatment along with estimates of the frequency and duration of therapy throughout the individual’s experience living in one’s affirmed gender. Review the criteria above under “Criteria for Coverage of Gender Reassignment Surgery and Related Services” for required surgical referral letters from qualified mental health professionals.

Male-to-Female (MtF) surgical procedures performed as part of gender reassignment services for an individual who has met the above criteria for gender dysphoria may be considered medically necessary and include the following:

• Breast modification, including but not limited to breast enlargement, breast augmentation, mastopexy, implant insertion, and silicone injections, and nipple or areola reconstruction

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

Breast Augmentation Note: augmentation mammoplasty (including breast prosthesis if necessary) if the physician prescribing hormones and the surgeon have documented that breast enlargement after undergoing hormone treatment for 12 months is not sufficient for comfort in the social role

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

Breast augmentation with nipple/areola reconstruction surgery if ALL of the following are met:

  • One (1) referral letter from mental health professional with a minimum of a Master’s degree or Ph.D. in clinical psychology (See ADDITIONAL INFORMATION for letter criteria)

  • Documentation of 12 months of continuous hormonal therapy (unless the individual has a medical contraindication or is unable or unwilling to take hormones).

Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Breast Reconstruction Policy:

The individual being considered for surgery and related services must meet ALL the following criteria. The individual must have:

  • Reached the age of majority; AND
  • The capacity to make a fully informed decision and to consent for treatment; AND
  • Been diagnosed with persistent, well-documented gender dysphoria; AND
  • The required referrals prior to any surgery or related service(s):

o Prior to breast/chest surgery, e.g., mastectomy, chest reconstruction, or breast augmentation, one required referral from the individual’s qualified mental health professionals (see NOTE 1 below) competent in the assessment and treatment of gender dysphoria

NOTE 1: Psychotherapy and Mental Health Services:

Psychotherapy is not required for gender reassignment services except when a mental health professional recommends psychotherapy based on initial assessment prior to gender reassignment surgery. The recommendation for psychotherapy must specify the goals of treatment along with estimates of the frequency and duration of therapy throughout the individual’s experience living in one’s affirmed gender. Review the criteria above under “Criteria for Coverage of Gender Reassignment Surgery and Related Services” for required surgical referral letters from qualified mental health professionals.

Male-to-Female (MtF) surgical procedures performed as part of gender reassignment services for an individual who has met the above criteria for gender dysphoria may be considered medically necessary and include the following:

• Breast modification, including but not limited to breast enlargement, breast augmentation, mastopexy, implant insertion, and silicone injections, and nipple or areola reconstruction

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

When a benefit for gender reassignment surgery exists, it is considered a covered service when the documentation submitted confirms that all of the following eligibility criteria are met:

  • The individual is at least 18 years of age, AND
  • The individual has been diagnosed with the gender dysphoria based on the current edition of the Diagnostic and Statistical Manual of Mental Disorders, AND
  • The individual initially has successfully lived and worked within the desired gender role full-time for at least 12 months (real-life experience) without returning to the original gender, AND
  • In addition to living and working with the desired gender role full-time for a minimum of 12 months, a minimum of an additional 12 continuous months of hormone replacement therapy must occur, AND
  • After the minimum of 24 continuous months of living and working within the desired gender role full-time and hormone replacement therapy, the individual should undergo repeat comprehensive independent behavioral health evaluation.
  • Regular psychotherapy and counseling should be available through the member's individualized gender reassignment pathway.

When a covered benefit for gender reassignment surgery exists and all of the above eligibility criteria are met, the following surgeries are Medically Necessary for transwomen (male to female):

Breast Augmentation (19324-19325) Note: augmentation mammoplasty (including breast prosthesis if necessary) if the physician prescribing hormones and the surgeon have documented that breast enlargement after undergoing hormone treatment for 12 months is not sufficient for comfort in the social role

Policy: Gender Affirmation Surgeries

Breast Reconstruction Policy:

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).

Policy: Gender Affirming Interventions for Gender Dysphoria

Breast Reconstruction Policy:

All of the following general criteria must be met for surgical gender affirming interventions for gender dysphoria to be considered for coverage:

A. Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); and

B. Clinical records document that the patient has the capacity to make fully informed decisions and consent for intervention, and that any other mental health condition, if present, is adequately controlled; and

C. At least 2 licensed mental health professionals have diagnosed gender dysphoria, and recommend surgical intervention (Note: only 1 mental health professional referral is required for mastectomy); and

D. Documentation of continuous hormonal therapy for at least 12 months, unless there is a documented contraindication to hormonal therapy (Notes: hormonal therapy is not required prior to mastectomy; hormonal therapy for at least 6 months is required for endometrial ablation); and

E. Twelve months of living in a role that is congruent with the patient’s identity.

Any of the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the intervention would improve otherwise documented significant gender dysphoria, and all of Criteria II.A. above are met:

1. Breast augmentation

5. Mastopexy

Policy: Gender Reassignment Surgery for Gender Dysphoria

Breast Reconstruction Policy:

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.
Policy: Gender Reassignment Services

Breast Reconstruction Policy:

  1. The individual is age 18 years or older; and
  2. The individual has a confirmed diagnosis of gender dysphoria including all the following: ...
  3. For those without a medical contraindication to hormonal therapy, the individual has undergone a minimum of 12 continuous months of hormonal therapy that was recommended by a mental health professional and supervised by a physician over the entire 12-month period; and

  4. Documentation that the individual has completed a minimum of 12 months of successful continuous full-time, real-life experience in their desired gender, across a wide span of life experiences and events that may occur throughout the year (i.e., holidays, vacations, season-specific school and/or work experience, family events), where;

    1. the documentation includes the start date of living in the desired gender role; and

    2. verification via medical or mental health professional* communication with persons who have related to the individual in an identity-congruent gender role, or documentation of a legal name change; and

    3. regular active participation in a recognized gender dysphoria treatment program; and

  5. The individual has received the following referrals for surgery:

    1. One letter of referral from a licensed mental health professional, if the individual is seeking breast/chest surgery (e.g., mastectomy, chest reconstruction, or augmentation mammoplasty)

The gender reassignment surgeries that may be performed for transwomen (male to female) that meet the above 5 criteria include but are not limited to: ... Mammoplasty: breast augmentation

Policy: Gender Dysphoria

Breast Reconstruction Policy:

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

Policy: Gender Affirming/Reassignment Surgery — New York

Breast Reconstruction Policy:

Gender affirming/reassignment surgery will be covered for members greater than or equal to 18 years of age.

The request must be accompanied by letters from two qualified New York State (NYS) licensed health professionals, acting within the scope of his/her practice, who have independently assessed the member and are referring the member for the surgery.

One letter must be from a psychiatrist, psychologist, psychiatric nurse practitioner (NP) or licensed clinical social worker (CSW) with whom the member has an established and ongoing relationship.

The other letter may be from a psychiatrist, psychologist, physician, psychiatric NP or licensed CSW who has only an evaluative role with the member.

Together, the letters must establish that the member:

  1. Has a persistent and well-documented case of gender dysphoria
  2. Has received hormone therapy (not prerequisite for mastectomy) appropriate to member’s gender goals for a minimum of 12 months prior to seeking genital surgery (unless medically contraindicated or the member is otherwise unable to take hormones)
  3. Has lived 12 months in gender role congruent with member’s gender identity (inclusive of binary and Nonbinary Gender) and has received mental health counseling, as deemed medically necessary, during that time
  4. Has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery
  5. Has the capacity to make fully informed decisions and consent to treatment

Breast augmentation is considered medically necessary provided that the member has completed a minimum of 24 months of hormone therapy, during which time breast growth has been negligible; or hormone therapy is medically contraindicated; or the member is otherwise unable to take hormones

Policy: Transgender Services

Breast Reconstruction Policy:

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:

  1. The member is 18 years of age or older;
  2. 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.
  3. 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;
  4. The member has lived as their chosen or reassigned gender full-time for 12 months or more; (3 and 4 may occur concurrently)
  5. 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.
Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

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.

Policy: Gender Dysphoria and Gender Confirmation Treatment

Breast Reconstruction Policy:

Gender confirming services may be considered medically necessary when supporting documentation is provided by the clinicians (physicians and mental health professionals) confirms ALL of the following:

  • The member is 18 years of age or older *; and
  • The member has been diagnosed with Gender Dysphoria; and
  • The member has expressed a desire to transition his/her body to the preferred gender through surgery and hormone replacement therapy** (if not otherwise contraindicated); and
  • The member has completed a psychological assessment (psychotherapy may be recommended, but is not required) by a behavioral health professional with a doctoral degree (Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D) who is capable of adequately evaluating if the candidate has any co-morbid psychiatric conditions; and; 
  • A medical evaluation has been completed by a MD/DO; and
  • The gender confirming surgery has been recommended by:
    • “One referral from a qualified mental health professional is needed for breast/chest surgery (e.g., mastectomy, chest reconstruction, or augmentation mammoplasty)”
Policy: Transgender Health Services

Breast Reconstruction Policy:

Harvard Pilgrim Health Care (HPHC) considers transgender surgical services as medically necessary when documentation and letters from the attending clinician(s) and mental health professional (MHP) responsible for managing the member’s hormone therapies (if appropriate) and/or other related transgender care confirm ALL the following:

  1. Member age 18 years or older has been diagnosed (by an appropriately trained MHP) with gender dysphoria/gender incongruence; AND
  2. Member wishes to make his/her body as congruent as possible with the gender identity through surgery and/or hormone replacement (if appropriate); AND
  3. Transgender surgery has been recommended by treating clinicians

Transfeminine surgeries covered include:

  • Augmentation mammoplasty

 

Policy: Transgender Health Services

Breast Reconstruction Policy:

Harvard Pilgrim Stride (HMO) Medicare Advantage considers transgender surgical services as medically necessary when documentation and letters from the attending clinician(s) and mental health professional (MHP) responsible for managing the member’s hormone therapies (if appropriate) and/or other related transgender care confirm ALL the following:

  1. Member age 18 years or older has been diagnosed (by an appropriately trained MHP) with gender dysphoria/gender incongruence; AND
  2. Member wishes to make his/her body as congruent as possible with the gender identity through surgery and/or hormone replacement (if appropriate); AND
  3. Transgender surgery has been recommended by treating clinicians

Transfeminine surgeries covered include:

  • Augmentation mammoplasty
Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

A. Age > 18

a. Exception: in adolescent female to male patients < 18 years, chest surgery may be considered after one year of testosterone treatment;

B. Persistent, well-documented gender dysphoria with evidence the member has lived at least 12 continuous months in a gender role that is congruent with their gender identity (not required for mastectomy in female to male except for those < 18 years);

C. Capacity to make a fully informed decision and to consent for treatment;

D. If significant medical or mental health concerns are present, they must be reasonably well controlled;

E. Written referral letter(s) from a qualified mental health practitioner (See below for qualifications) based on the type of surgery (one referral for chest surgery; two referrals for genital surgery) and containing the following:

1. The client’s general identifying characteristics;

2. Results of the client’s psychosocial assessment, including any diagnoses;

3. The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;

4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery;

5. A statement about the fact that informed consent has been obtained from the patient;

6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

7. The degree to which the member has followed the standards of care to date and the likelihood of future compliance

8. For providers working within a multidisciplinary specialty team, a letter may not be necessary, rather, the assessment and recommendation can be documented in the patient’s chart.

Note: Although not an explicit criterion, it is recommended that male to female individuals undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

It is the policy of Health Net of California that each of the following procedures, when used specifically to improve the appearance of an individual undergoing gender reassignment surgery or actively participating in a documented gender reassignment surgery treatment plan, must be evaluated to determine if it is medically necessary reconstructive surgery to create a normal appearance for the gender with which the member identifies. Prior to making a clinical determination of coverage, it may be necessary to consult with a qualified and licensed mental health professional and the treating surgeon. ... Breast augmentation

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

GRS may be considered medically necessary when ALL of the following are met:

  • The individual is greater than or equal to 18 years of age; and
  • The individual has the capacity to make a fully informed decision and to consent for treatment; and
  • The individual has been diagnosed with the gender dysphoria of transsexualism, including ALL of the following:
    • The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
    • The individual's transsexual identity has been present persistently for at least two (2) years; and
    • The disorder is not a symptom of another mental disorder or a chromosomal abnormality; and
    • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The individual is an active participant in a recognized gender identity treatment program and demonstrates ALL of the following conditions:
    • The individual has successfully lived and worked within the desired gender role full-time for at least 12 months (real life experience) without returning to the original gender; and
    • Initiation of hormonal therapy or breast surgery recommended by a qualified health professional with written documentation submitted to the physician responsible for the medical treatment; and
    • Documentation of at least 12 months of continuous hormonal sex reassignment therapy, unless medically contraindicated (may be simultaneous with real life experience); and
    • Recommendation for sex reassignment surgery by two (2) qualified mental health professionals who recommend sex reassignment surgery with written documentation submitted to the physician performing the genital surgery*; and
    • Separate evaluation by the physician performing the genital surgery.

* At least one (1) letter must be a comprehensive report. Two (2) separate letters or one (1) letter with two (2) signatures is acceptable. One (1) letter from a Master’s degree mental health professional is acceptable if the second letter is from a psychiatrist or Ph.D. (clinical psychologist).

When ALL of the above criteria are met, the following breast/genital surgeries may be considered medically necessary for the following indications:

MTF:

  • Breast augmentation
Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

GRS may be considered medically necessary when ALL of the following are met:

  • The individual is greater than or equal to 18 years of age; and
  • The individual has the capacity to make a fully informed decision and to consent for treatment; and
  • The individual has been diagnosed with the gender dysphoria of transsexualism, including ALL of the following:
    • The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and
    • The individual's transsexual identity has been present persistently for at least two (2) years; and
    • The disorder is not a symptom of another mental disorder or a chromosomal abnormality; and
    • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The individual is an active participant in a recognized gender identity treatment program and demonstrates ALL of the following conditions:
    • The individual has successfully lived and worked within the desired gender role full-time for at least 12 months (real life experience) without returning to the original gender; and
    • Initiation of hormonal therapy or breast surgery recommended by a qualified health professional with written documentation submitted to the physician responsible for the medical treatment; and
    • Documentation of at least 12 months of continuous hormonal sex reassignment therapy, unless medically contraindicated (may be simultaneous with real life experience); and
    • Recommendation for sex reassignment surgery by two (2) qualified mental health professionals who recommend sex reassignment surgery with written documentation submitted to the physician performing the genital surgery*; and
    • Separate evaluation by the physician performing the genital surgery.

* At least one (1) letter must be a comprehensive report. Two (2) separate letters or one (1) letter with two (2) signatures is acceptable. One (1) letter from a Master’s degree mental health professional is acceptable if the second letter is from a psychiatrist or Ph.D. (clinical psychologist).

When ALL of the above criteria are met, the following breast/genital surgeries may be considered medically necessary for the following indications:

MTF:

  • Breast augmentation
Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

Breast augmentation may be considered when 18 months of hormone treatment fails to result in breast enlargement that is sufficient for the individual’s comfort in the female gender role.

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

B. Criteria for breast augmentation (implants/lipofiling) in male-to-female members:

1. Single letter of referral from a qualified mental health professional (see Policy Guidelines** ***), and

2. Persistent, well-documented gender dysphoria (see Policy Guidelines*); and

3. Capacity to make a fully informed decision and to give consent for treatment; and

4. Age of majority (18 years of age or older); and

5. If significant medical or mental health concerns are present, they must be reasonably well controlled.

(NOTE: Although not an explicit criterion, it is recommended that male-to-female members undergo feminizing hormone therapy (minimum of 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical/aesthetic results.)

Policy: Gender Reassignment Services

Breast Reconstruction Policy:

Breast Augmentation may be considered medically necessary as part of male to female gender reassignment when breast enlargement, after undergoing hormone treatment for 24 months, is not sufficient for comfort in the social gender role and when all of the following criteria are met:

  1. The individual has capacity to make fully informed decisions and consent for treatment; and
  2. The individual has been diagnosed with gender dysphoria, and exhibits all of the following:
    • The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and

    • The transsexual identity has been present persistently for at least two years; and

    • The disorder is not a symptom of another mental disorder; and

    • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and

  3. If the individual has significant, outstanding medical or mental health conditions present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated
  4. One referral from a qualified mental health professional who has independently assessed the individual.
Policy: Treatment of Gender Dysphoria

Breast Reconstruction Policy:

BREAST AUGMENTATION
Breast augmentation in transwomen (male to female) is considered medically necessary, and therefore covered, when all of the following criteria are met:

  • The individual has persistent, well documented gender dysphoria in accordance with the criteria established in the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, [DSM-5] 
  • Breast augmentation is recommended by a qualified professional provider who has consistently monitored the individual up to the time of surgery
    • One referral letter and/or chart documentation must be written from the mental health professional provider who consistently monitored the individual throughout their psychotherapy or any other evaluation to the professional provider who will be responsible for the individual's treatment.
  • The individual is at least 18 years of age
  • The individual, unless medically contraindicated, has used feminizing hormones continuously and responsibly (which may include screenings and follow-ups with the professional provider) for a 12-month period 
  • The individual, if required by a mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider 
  • If the individual has significant medical or mental health concerns, they are reasonably well controlled
Policy: Treatment of Gender Dysphoria

Breast Reconstruction Policy:

BREAST AUGMENTATION
Breast augmentation is considered medically necessary and, therefore, covered, when all of the following criteria are met:

  • The individual has persistent, well-documented gender dysphoria in accordance with the criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, [DSM-5].
  • Breast augmentation is recommended by a qualified professional provider who has consistently monitored the individual up to the time of surgery.
    • One referral letter and/or chart documentation must be written from the mental health professional provider who consistently monitored the individual throughout their psychotherapy or any other evaluation to the professional provider who will be responsible for the individual's treatment.
  • The individual is at least 18 years of age.
  • The individual, unless medically contraindicated, has used feminizing hormones continuously and responsibly (which may include screenings and follow-ups with the professional provider) for a 12-month period.
  • The individual, if required by a mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider.
  • If the individual has significant medical or mental health concerns, they are reasonably well controlled.
Policy: Gender Dysphoria

Breast Reconstruction Policy:

Chest and Genital Gender-Affirming Surgical Consultation:

  1. The individual must have a diagnosis of persistent gender dysphoria.
  2. The individual must be able to provide informed consent. Feminizing/masculinizing gender-affirming surgery will lead to irreversible physical changes and/or potential adverse effects, and the individual must have the capacity to make a fully informed decision to consent to treatment.
  3. A Medical Evaluation Form is to be completed (see Attachment B). Alternatively, the Provider may submit the same content in the clinical documentation.
  4. The Provider or Therapist Documentation Form for Evaluation for Transgender Surgery is to be completed (see Attachment C). Alternatively, a letter from the Provider addressing the same content as Attachment C is acceptable.

a. One form/letter (for chest surgeries) from an individual’s treating Primary Care Provider or mental health professional endorsing the request in writing is required for the following chest surgeries:

i. (M to F) Augmentation mammoplasty;

Policy: Gender Affirmation Treatment & Procedures

Breast Reconstruction Policy:

Breast/Chest Surgery: When benefits are provided under the member’s contract, JHHC will authorize gender reassignment breast/chest surgery when ALL of the following criteria are met:

a. One letter of referral (letter of medical necessity) from a licensed mental health professional, AND

b. Persistent, well-documented gender dysphoria, AND

c. Capacity to make fully informed decisions and consent for treatment, AND;

d. The member has reached the legal age of medical consent, AND

e. If significant medical or mental health issues present, they must be sufficiently (reasonably well) controlled

f. Female-to-male breast/chest surgery does not require hormone therapy as a pre-requisite for the covered procedures noted in section E. 1. a. below.

g. Male-to-female breast/chest surgery is covered when ALL of the following have been met for the covered procedure noted in section E. 1. c. below:

i. Breast size measures less than Tanner stage 5 after undergoing 12 months of hormone therapy, AND

ii. Breast size continues to cause clinically significant distress in social, occupational, or other areas of functioning as documented by a qualified mental health provider as identified in section

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

Requirements for breast augmentation for male-to-female members:

A. Single letter of referral from a qualified mental health professional; and

B. Persistent, well-documented gender dysphoria per DSM 5 Gender Dysphoria; and

C. Capacity to make a fully informed decision and to consent for treatment; and

D. Age 18 years or older (Note: age requirement will not be applied to augmentation in Male-to-Female patients if the surgeon, the primary care provider, and the qualified mental health professional unanimously document the medical necessity of earlier intervention)

E. If significant medical or mental health concerns are present, they must be reasonably well controlled. The health plan may require a second opinion regarding the patient’s stability prior to surgery if in question; and

F. Twelve months of living in a gender role that is congruent with their gender identity (real life experience) and

G. Twelve months of continuous hormone therapy as appropriate to the member’s gender goals.

If the referring medical provider or mental health provider requests surgical intervention prior to the patient’s completion of 12 months of hormone therapy and/or living in desired gender, the surgeon, the primary care provider, and the qualified mental health professional must submit evidence of medical necessity and clear rationale for the proposed surgical intervention to be done early. The three providers must submit written documentation to the plan that includes:

a. A comprehensive, coordinated treatment plan with evidence that all treatment plan criteria for surgery and treatment goals have been met; and

b. Clear rationale for the variation from either the 12-month period of hormone therapy and/or living for 12 months in desired gender; and

c. Patient understands the treatment plan, risks and benefits of surgery prior to completing the 12month period; and

d. The plan will determine authorization and consent to care based on medical necessity from the documentation outlined in A-G above.

The criteria above apply for only initial male to female augmentation mammaplasty, any additional breast augmentation after an initial mammaplasty is considered a cosmetic procedure, and therefore, a contract exclusion.

Policy: Transgender Surgery

Breast Reconstruction Policy:

MtF members are eligible for Breast Augmentation if they meet all of the following criteria:

  1. Single letter of referral from a qualified mental health professional; and
  2. Persistent, well-documented gender dysphoria per DSM 5 Gender Dysphoria; and
  3. Capacity to make a fully informed decision and to consent for treatment; and
  4. Age 18 years or older (Note: age requirement will not be applied to augmentation in Male-to-Female patients if the surgeon, the primary care provider, and the qualified mental health professional unanimously document the medical necessity of earlier intervention); and
  5. If significant medical or mental health concerns are present, they must be reasonably well controlled. The health plan may require a second opinion regarding the patient’s stability prior to surgery if in question; and
  6. Twelve months of living in a gender role that is congruent with their gender identity (real life experience) and
  7. Twelve months of continuous hormone therapy as appropriate to the member’s gender goals.

If the referring medical provider or mental health provider requests surgical intervention prior to the patient’s completion of 12 months of hormone therapy and/or living in desired gender, the surgeon, the primary care provider, and the qualified mental health professional must submit evidence of medical necessity and clear rationale for the proposed surgical intervention to be done early.

The three providers must submit written documentation to the plan that includes:

a. A comprehensive, coordinated treatment plan with evidence that all treatment plan criteria for surgery and treatment goals have been met; and

b. Clear rationale for the variation from either the 12-month period of hormone therapy and/or living for 12 months in desired gender; and

c. Patient understands the treatment plan, risks and benefits of surgery prior to completing the 12- month period.

The plan will determine authorization and consent to care based on medical necessity from the documentation outlined in 1-7 above. The criteria above apply for only initial male to female augmentation mammaplasty, any additional breast augmentation after an initial mammaplasty is considered a cosmetic procedure, and therefore, a contract exclusion.

Policy: UR 20.7 WA PEBB Breast Augmentation Surgery Criteria for Gender Transition

Breast Reconstruction Policy:

  • This policy pertains to Washington PEBB members only effective 1/1/17.
  • OHP (Oregon Medicaid) see OHP Prioritized List, Guideline Note 127 for treatment of Gender Dysphoria.
  • For all other groups, breast augmentation is not covered. See UR 65 Transgender Surgery UM Criteria for covered gender transition procedures.

Breast augmentation will require prior-authorization utilizing the following coverage criteria

  1. Diagnosis of gender dysphoria (male to female) AND
  2. Has received at least 1 year of hormone therapy (unless there are contraindications) AND ONE:
    • No measurable cup size growth, defined as less than an A cup, in one or both breasts OR
    • Asymmetry where one breast did not have a measurable cup size growth, defined as less than an A cup.
  3. Documentation from surgeon of current cup size and proposed changes as well as photo documentation.
Policy: Gender confirmation treatment (medical and surgical)

Breast Reconstruction Policy:

I. Criteria:

A. Member is an adult, age 18 years or older, or documented as an emancipated adolescent, or has documentation of appropriate consent from parent or guardian.

B. Member has the capacity to make fully informed decisions and consent for treatment.

C. Member has established diagnosis of persistent, well-documented Gender Confirmation Surgery (GCS) as defined in the DSM-5 TR criteria of GD in adolescents and adults: ...

The diagnosis has been made and documented by a professional appropriately trained in transgender medicine. (See glossary for definition of “appropriately trained in transgender medicine.”)

E. Member desires to live and be accepted as a person of the opposite sex, usually accompanied by the wish to make his/her body conform as much as possible with the preferred sex through surgery and hormone treatment.

F. Has had real-life experience of at least 12 months.

G. GD is not a symptom of another mental disorder.

II. Hormone therapy:

A. Member 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 with documentation of member’s compliance and the type, frequency and route of administration.

III. Psychotherapy:

A. Regular participation in psychotherapy throughout the real-life experience when recommended by a treating medical or mental health practitioner.

B. If significant medical or mental health issues are present, documentation is required indicating they are reasonably well controlled.

C. If the member is diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), documentation must indicate an effort has been made to improve these conditions with psychotropic medications and/or psychotherapy before GCS is considered.

IV. Referrals:

A. Three referrals are necessary:

1.One referral must be from the member’s medical provider or surgical provider who will be rendering longitudinal care.

2. Two referrals for genital surgery or one referral for breast or chest surgery; one of which must be from a qualified mental health professionals who has independently assessed the individual. (WPATH, p27)

3. If the first mental health referral is from the member’s psychotherapist, the second referral should be from an independent evaluator.

4. At least one of the mental health professionals submitting a letter must be appropriately trained in transgender medicine. (See glossary.)

The following surgeries required for male-to-female members are medically necessary if all the criteria listed in sections I. through V. are met:

1. Genital surgery and breast surgery: ... f. Mammaplasty, augmentation. g. Nipple/areola reconstruction.

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

One comprehensive evaluation and recommendation within the last six months from a licensed mental health professional (see Guidelines below) AND

  • Diagnosis of gender dysphoria (formerly gender identity disorder) confirmed by the evaluating mental health professional AND
  • 18 years of age or older AND
  • No medical contraindications to surgery

For augmentation mammaplasty for male to female patients, one of the following:

  • 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

Note: The criteria above apply for initial male to female augmentation mammaplasty, Additional breast augmentation after an initial augmentation mammaplasty is considered to be a feminization or cosmetic procedure, and therefore, member contract stipulations for feminization or cosmetic procedures (either contract exclusion or coverage criteria, whichever is applicable for the member’s health plan) apply.

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

Gender reassignment surgery is medically necessary when all of the following criteria are met (adapted from the World Professional Association for Transgender Health Inc., Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, (Seventh Version 2012):

A. The member must have a diagnosis of gender dysphoria from the Diagnostic and Statistical Manual of Mental Disorders [DSM 5-TR, 2013] section 302.6.

B. Eligibility criteria for specific surgeries:

1. Criteria for mastectomy for female to male

a. The member has persistent, well-documented gender dysphoria

b. The member is 18 years of age or older

c. The member has the capacity to make a fully informed decision and to consent for treatment

d. If significant medical or mental health concerns are present, documentation must support that they are reasonably well-controlled.

NOTE: Hormonal treatment is not a prerequisite for mastectomy.

2. Criteria for breast augmentation for male to female

a. The member has persistent, well-documented gender dysphoria

b. The member is 18 years of age or older

c. The member has the capacity to make a fully informed decision and to consent for treatment

d. If significant medical or mental health concerns are present, documentation must support that they are reasonably well-controlled

e. Twelve months of continuous hormonal gender reassignment treatment must be completed.

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

Breast/chest surgery for Male-to-Female (MtF) members is medically appropriate with ALL of the following: (Hormone therapy is not a prerequisite)

a. One referral from qualified behavioral/mental health professional (See Appendix B for referral letter requirements)

b. Persistent, well-documented gender dysphoria

c. Age of majority (18 years of age or older)

d. If significant medical or mental health concerns are present, they must be reasonably well controlled.

Policy: Gender Dysphoria Treatment

Breast Reconstruction Policy:

Gender reassignment surgeries/procedures listed in Tables I and II require prior authorization and are covered for transmen or transwomen when documentation submitted confirms that all of the following criteria are met:

  • Member is 18 years of age or older
  • Member has the capacity to make fully informed decisions including consent to treatment.
  • Gender Dysphoria has been diagnosed by qualified health provider(s) and is a persistent diagnosis
  • Member has successfully lived full-time in the desired gender role without retuning to the original gender for a minimum of 12 months.
  • Face to face comprehensive evaluation and treatment plan by the provider administering hormonal therapy and by the *surgeon performing requested surgery.
  • A behavioral health evaluation, supporting candidacy for gender-confirming surgery, performed within 6 months of the request for authorization for surgery.
  • Attestation that the member is adhering to medical and behavioral health treatment as recommended and is medically and behaviorally stable.
  • Attestation that the member has access to primary care provided by a clinician who is has an understanding of gender dysphoria and who can perform and coordinate follow up care including appropriate screenings and monitoring.
  • The treatment plan must conform to WPATH standards and/or to other evidence-based, agreed upon, external guidelines.
  • Surgeons must have demonstrated training, experience, and proficiency in performing the requested surgical procedure.
  • Breast Augmentation mammaplasty requires documentation by the physician prescribing hormones and the surgeon that breast enlargement after undergoing hormone treatment for 12 months is not sufficient for comfort in the social role.
Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

One comprehensive evaluation and recommendation within the last six months from a licensed mental health professional (see Guidelines below) AND

  • Diagnosis of gender dysphoria (formerly gender identity disorder) confirmed by the evaluating mental health professional AND
  • 18 years of age or older AND
  • No medical contraindications to surgery

For augmentation mammaplasty for male to female patients, one of the following:

  • 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

Note: The criteria above apply for initial male to female augmentation mammaplasty, Additional breast augmentation after an initial augmentation mammaplasty is considered to be a feminization or cosmetic procedure, and therefore, member contract stipulations for feminization or cosmetic procedures (either contract exclusion or coverage criteria, whichever is applicable for the member’s health plan) apply.

Policy: Gender Reassignment

Breast Reconstruction Policy:

Premier Health Plan considers Gender Reassignment medically necessary for ALL of the following indications:

  1. The patient is at least 18 years old;
  2. The patient has the mental capacity for fully-informed consent
  3. The patient has been diagnosed with Gender Dysphoria (per the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) per the American Psychiatric Association, see definition in Background section) and therefore meets all the following indications:
    • The patient is participating in a recognized gender identity treatment group

    • The patient has the desire to live and be accepted as a member of the opposite sex

    • The transsexual identity of the patient has been present persistently for at least two years and is well-documented

    • Their gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning;

  4. The patient has undergone a minimum of 12 months of continuous hormonal therapy as appropriate to the patient’s gender goals (unless hormone therapy is contraindicated)
  5. The patient has completed 12 continuous months of living in the gender role that is congruent with their gender identity
  6. The patient has at least two referrals from qualified mental health professionals (see definition in Background section) who have independently assessed the patient

The following procedures may be considered cosmetic and therefore not medically necessary:

Breast Augmentation (unless for MtF when an appropriate trial of hormone therapy has not resulted in any breast enlargement)

Policy: Gender dysphoria

Breast Reconstruction Policy:

Candidate Criteria:

A. The member is an adult age 18 or older, or documented as an emancipated adolescent, or has documentation of appropriate consent from parent or guardian.

B. The member has the capacity to make fully informed decisions and consent for treatment.

C. The member has received a diagnosis of gender dysphoria by a qualified health professional.

The diagnosis must be based on:

  1. Strong and persistent cross-gender identification. In adolescents and adults, the condition is manifested by symptoms such as a stated desire to be the other gender, frequent passing as the other gender, desire to live or be treated as the other gender, or the conviction that he or she has the typical feelings and reactors of the other gender.
  2. Persistent discomfort (dysphoria) with his/her gender or sense of inappropriateness in the gender role of that sex.
  3. The dysphoria is not concurrent with a physical intersex condition.
  4. The dysphoria causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The member desires to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his/her body conform as much as possible to the preferred sex through surgery and hormone treatment.

E. The member has had real-life experience of at least 12 months in his/her desired gender.

F. Gender dysphoria is not a symptom of another mental disorder.

Referrals for Surgical Procedures

One or more referrals from a qualified mental health professional are necessary for certain procedures, including:

A. Breast/chest surgery, including mastectomy, chest reconstruction, and augmentation mammoplasty (one letter).

B. Genital surgery, including hysterectomy, salpingo-oophorectomy, orchiectomy, and genital reconstruction (two letters, one from the member’s psychotherapist, one from a professional who had an evaluative role).

Referral letters should include member identification, results of psychosocial assessments, duration of practitioner relationship with the member, a statement explaining that the criteria for surgery have been met, a statement that the member has given informed consent, and a statement that the practitioner is available for coordination of care.

Breast/Chest Surgery. Breast augmentation and mastectomy for female to male (transmen) and creation of male chest for male to female (transwomen) members are considered medically necessary when the following criteria are met:

  1. Persistent gender dysphoria is well documented.
  2. Member has the capacity to make informed decisions and consent to treatment.
  3. Member is of majority (adults only).
  4. Any significant medical or mental health concerns are controlled.
  5. Member has had at least 12 months of feminizing hormone therapy (recommended for breast augmentation).
  6. One letter of referral is submitted
Policy: Gender Affirming Interventions for Gender Dysphoria

Breast Reconstruction Policy:

All of the following general criteria must be met for surgical gender affirming interventions for gender dysphoria to be considered for coverage:

A. Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); and

B. Clinical records document that the patient has the capacity to make fully informed decisions and consent for intervention, and that any other mental health condition, if present, is adequately controlled; and

C. At least 2 licensed mental health professionals have diagnosed gender dysphoria, and recommend surgical intervention (Note: only 1 mental health professional referral is required for mastectomy); and

D. Documentation of continuous hormonal therapy for at least 12 months, unless there is a documented contraindication to hormonal therapy (Notes: hormonal therapy is not required prior to mastectomy; hormonal therapy for at least 6 months is required for endometrial ablation); and

E. Twelve months of living in a role that is congruent with the patient’s identity.

Any of the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the intervention would improve otherwise documented significant gender dysphoria, and all of Criteria II.A.-E. above are met:

1. Breast augmentation

Policy: Medical Necessity Guidelines: Transgender Surgical Procedures

Breast Reconstruction Policy:

Tufts Health Plan may authorize the coverage of transgender surgery procedures listed in this guideline for Members who have this benefit included in their plan document when ALL of the following criteria are met:

  1. The Member 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
  2. The Member has received continuous hormone therapy for 12 months or more under the supervision of a physician. Exceptions: The Member has a medical contraindication that is attested to by the treating endocrinologist; or when the request is mastectomy only for female to male surgery.
  3. The Member has lived as their reassigned gender full-time for 12 months or more. (Numbers 2 and 3 may occur concurrently.)
  4. The Member’s medical and mental health providers document that there are no contraindications to the planned surgery and agree with the plan (within three months of the Prior Authorization request).

When the above guidelines are met, Tufts Health Plan may authorize one or more of the following covered surgeries, up to the Member’s benefit limit: .. Mammaplasty (breast augmentation)

Policy: Gender Affirming Interventions for Gender Dysphoria: Clinical Criteria and Poli…

Breast Reconstruction Policy:

A. Gender reassignment surgery (see UMP clinical criteria policy and Regence medical policy 153 guidelines) may be considered medically necessary in the treatment of gender dysphoria when all of the following criteria are met:

1. Age at least 18 years. For patients younger than 18 years of age, mastectomy may be considered a medically necessary surgical procedures. Other requirements outlined in this section must be met to proceed with mastectomy in those younger than 18 years of age.

2. Clinical records document that the patient has the capacity to make fully informed decisions and consent for treatment as part of a comprehensive, patient-centered treatment plan; and that any other mental health condition, if present, is adequately controlled; and

3. At least 2 licensed mental health professionals have diagnosed gender dysphoria, and recommend surgical treatment (*Only one mental health professional referral is required for mastectomy); and

a) Assesses the patient and makes or confirms the diagnosis of gender dysphoria as defined by the DSM-V criteria, and

b) Determines or confirms that the gender dysphoria is not due to another mental or physical health condition; and

4. Documentation of continuous hormonal therapy for at least 12 months, unless there is a documented medical contraindication to hormonal therapy. Hormonal therapy is not required prior to mastectomy; and

5. Twelve months of living in a gender role that is congruent with the patient’s gender identity.

Breast augmentation will require preauthorization with following criteria:

a) Documentation of continuous hormonal therapy for at least 12 months, unless there is documented medical contraindication to hormonal therapy; and

b) Have not reached a Tanner Stage 5.

Policy: Gender Dysphoria and Gender Reassignment Surgery (NCD 140.9) (Medicare Advantag…

Breast Reconstruction Policy:

In the absence of an NCD, coverage determinations for gender reassignment surgery, under section 1862(a)(1)(A) of the Social Security Act (the Act) and any other relevant statutory requirements, will continue to be made by the local Medicare Administrative Contractors (MACs) on a case-by-case basis.

Policy: Gender Dysphoria (Gender Identity Disorder) Treatment

Breast Reconstruction Policy:

Surgical treatment for Gender Dysphoria is covered when the Eligibility Qualifications for Surgery are met:

2. Surgery to change specified secondary sex characteristics, specifically:

Augmentation mammoplasty (including breast prosthesis if necessary) if the Physician prescribing hormones and the surgeon have documented that breast enlargement after undergoing hormone treatment for 18 months is not sufficient for comfort in the social role.

Clarifications for breast/chest surgery:

In addition to the Eligibility Qualifications listed above note the following:

A biologic male member that is only requesting a breast augmentation:

  • If able to take female hormones, the member should take the female hormones for at least 12-24 months* before being considered for bilateral breast augmentation since the member may achieve adequate breast development without surgery.
  • Although not a requirement for coverage, UnitedHealthcare recommends that the member complete at least 3 months of psychotherapy before having the breast augmentation.

*12 months is listed by WPATH v7, whereas, 2 years is listed by, Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline (2009).

Policy: Gender Dysphoria Treatment Excluding California

Breast Reconstruction Policy:

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The documentation requirements outline below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.

Policy: Gender Dysphoria (Gender Identity Disorder) Treatment

Breast Reconstruction Policy:

Coverage is available for medical, behavioral or pharmacological treatment that is Medically Necessary for Gender Dysphoria. UnitedHealthcare does not exclude or deny covered health care benefits based on associated diagnosis of Gender Dysphoria, or otherwise discriminate against the member on the basis that treatment is for Gender Dysphoria.

Policy: Gender Dysphoria (Gender Identity Disorder) Treatment

Breast Reconstruction Policy:

Coverage is available for medical, behavioral or pharmacological treatment that is Medically Necessary for Gender Dysphoria. UnitedHealthcare does not exclude or deny covered health care benefits based on associated diagnosis of Gender Dysphoria, or otherwise discriminate against the member on the basis that treatment is for Gender Dysphoria.

Policy: Gender Identity Services

Breast Reconstruction Policy:

The following services are considered cosmetic and do not meet criteria for medical necessity:

Coverage exceptions can be requested for review on an individual basis. ... breast enlargement procedures such as augmentation mammoplasty and implants

Policy: Gender Confirmation

Breast Reconstruction Policy:

Gender affirmation surgery involving feminizing breast/chest surgery is considered medically necessary and covered when all of the criteria below are met:

  1. A persistent, well-documented diagnosis of gender dysphoria (as outlined in the Definitions Section), including all of the following indications:
    • The desire to live and be accepted as a person whose gender is different than that assigned at birth, typically accompanied by the desire to make the physical body as congruent as possible with the identified gender through surgery and hormone treatment; and
    • The desire for alternate gender identity has been present for at least 6 months; and
    • The gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning; and
  2. Minimum 18 years of age* (see Variations); and
  3. The mental capacity for fully-informed consent as outlined in the Definitions Section; and
  4. A minimum of 12 months of continuous hormonal therapy, as recommended, as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable to take hormones).
  5. If significant medical or mental health issues are present, they must be reasonably well-controlled.
  • One referral from a qualified mental health professional (see Definitions Section) who has independently assessed the patient.

*Medicaid plans: For feminizing breast/chest surgery, patients younger than 18 years of age will be reviewed by a Medical Director.

Information Required for Review

In order to determine medical necessity for covered gender affirmation surgical procedures, adequate information must be furnished by the treating physician. Required documentation includes all of the following:

1. Letter of medical necessity including documentation of the following:

Date of birth

  • Diagnosis of persistent well-documented gender dysphoria according to DSM-V criteria as defined above
  • Capacity to provide fully-informed consent

2. Progress notes showing clear documentation of the experience in the gender role including the start date of living full time in the gender role. Notes must reflect the above listed appropriate number of months of living full time in a gender role that is congruent with their gender identity (if applicable).

3. Documentation of type(s) of hormonal therapy used, including dates of initiation and discontinuation (if applicable).

4. Documentation of breast size after 12 months of hormone therapy for MtF (if applicable).

5. Documentation that fully informed consent for the requested surgery was obtained.

6. Documentation (if applicable) of the presence and nature of any significant medical or mental health conditions, and documentation that they are reasonably well-controlled.

7. Documentation of one referral from qualified mental health professionals (see Definitions Section) who have independently assessed the patient.

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

  • One comprehensive evaluation and recommendation within the last six months from a licensed mental health professional (see Guidelines below), AND
  • Diagnosis of gender dysphoria (formerly gender identity disorder) confirmed by the evaluating mental health professional, AND
  • 18 years of age or older, AND
  • No medical contraindications to surgery

In addition, for augmentation mammaplasty for male to female patients, one of the following must be met:

  • 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

Note: The criteria above apply for initial male to female augmentation mammaplasty, Additional breast augmentation after an initial augmentation mammaplasty is considered to be a feminization or cosmetic procedure, and therefore, member contract stipulations for feminization or cosmetic procedures (either contract exclusion or coverage criteria, whichever is applicable for the member’s health plan) apply.

Correction or repair of complications:

Surgery to correct or repair complications of gender altering genital or breast/chest surgery may be considered medically necessary for complications that cause significant discomfort or significant functional impairment. Surgery to revise, or to reverse and redo, specific gender altering genital or breast/chest procedures, may be considered medically necessary when correction or repair of complications requires revision or undoing of the original genital or breast/chest procedure. (Example: Baker IV contracture after breast augmentation necessitates removal of the implants, and replacement with smaller implants.)

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

When all of the above criteria are met for gender reassignment surgery, the following genital surgeries may be considered for transwomen (male to female): ... Mammaplasty - breast augmentation

Covered CPT Codes – when criteria are met ... 19325 Mammaplasty, augmentation; with prosthetic implant

The following services and procedures are not a covered benefit: ... Breast augmentation (unless the individual has completed a minimum of 24 months of hormone therapy during which time breast growth has been negligible, or hormone therapy is medically contraindictated or the individual is otherwise unable to take hormones);