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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: 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:

When the criteria in II.A. above are met or have been met, the following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the particular requested procedure would improve otherwise documented significant gender dysphoria: 1. Breast augmentation ... 5. Mastopexy

The WPATH guideline recommends MTF patients undergo feminizing hormone therapy for a minimum of 12 months prior to augmentation surgery and lists specific criteria for breast augmentation (implants/lipofilling).

Policy: Transgender Services Benefits

Breast Reconstruction Policy:

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:

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: Transgender Services

Breast Reconstruction Policy:

Breast augmentation in male to female patients may be considered MEDICALLY NECESSARY when ALL of the following candidate criteria are met:

  • The candidate is at least 18 years of age,
    • If the candidate is less than 18 years of age, then treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet this criterion.
  • 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 sex other than one’s assigned sex, typically accompanied by the desire to make the physical body as congruent as possible with the identified sex through surgery and hormone treatment
    • The new gender identity has been present for at least 12 months
    • 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.
  • The candidate has completed a minimum of 12 months of successful continuous full time real-life experience in their new gender, with no returning to their original gender
    • If the candidate does not meet the 12 month time frame criteria of 12 months of successful continuous full time real-life experience in their new gender noted above, then the treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet these criteria. When submitted, the criteria of 12 months of successful continuous full time real-life experience in their new gender may be waived.
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."
Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Breast Reconstruction Policy:

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:

Primary Sexual Characteristic Gender Reassignment Chest and/or Genital Surgeries:

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.

Policy: Surgical Treatment of Gender Dysphoria

Breast Reconstruction Policy:

Breast augmentation may be considered medically necessary in male-to-female members when criteria 1 and 2 above are met; AND:

A.     The member is at least 18 years of age; and

B.     Presence of persistent, well-documented gender dysphoria; and

C.      The member has the capacity to make a fully informed decision and to give consent to treatment; and

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

E.      Documentation of 18 months of continuous hormone therapy with appropriate follow-up (unless contraindications exist); and

F.      Documentation that the amount of native breast tissue is inadequate for comfort in the social role of the male-to-female member

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

Breast Reconstruction Policy:

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 (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 Assignment Surgery and Gender Reassignment Surgery with Related Services

Breast Reconstruction Policy:

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 (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 Reassignment Surgery

Breast Reconstruction Policy:

The Plan will review all requests for breast augmentation for male-to-female (MtF) members 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.

Review criteria in the Medical Policy Statement section of the Breast Reconstruction medical policy, policy number OCA 3.43, (rather than the criteria included in this policy) for Plan prior authorization guidelines for the surgical removal of breast implants and the replacement of breast implants after implant explantation (when the breast implants were initially inserted for breast reconstruction as a component of gender reassignment surgery).

...

This policy includes medical criteria for the initial breast augmentation procedure as a component of gender reassignment surgery. 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. Review criteria in the Medical Policy Statement section of the Breast Reconstruction medical policy, policy number OCA 3.43, (rather than the criteria included in this policy) for Plan prior authorization guidelines for the surgical removal of breast implants and the replacement of breast implants after implant explantation (when the breast implants were initially inserted for breast reconstruction as a component of gender reassignment surgery).

Augmentation mammoplasty with implantation of breast prostheses is considered medically necessary for male-to-female members with persistent, well-documented gender dysphoria when criteria listed above in items A through C are met and ALL of the following criteria are met for the initial breast augmentation for gender reassignment surgery, as specified below in items (1) through (4):

(1) 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 DSM 5 criteria; AND

(2) The treating surgeon, in consultation with the qualified licensed mental health professional who has assessed the member, 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); AND

(3) 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

(4) The member has had 24 continuous months of physician-supervised hormone therapy, but the therapy has not resulted in breast development (unless hormone therapy is medically contraindicated for the member);

Policy: Transgender Services

Breast Reconstruction Policy:

The following procedures may be considered medically necessary when clinical information is submitted expressly documenting that the particular requested procedure would 
improve otherwise documented significant gender dysphoria:
1. Breast augmentation
...
5. Mastopexy 

Policy: Gender Reassignment Services

Breast Reconstruction Policy:

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:

It is recommended that MtF patients undergo feminizing hormone therapy for a minimum of twelve continuous months prior to breast surgery to maximize breast growth in order to obtain better surgical results.

Policy: Gender Affirming/Reassignment Surgery — Connecticut

Breast Reconstruction Policy:

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: Gender Affirming/Reassignment Surgery — New York

Breast Reconstruction Policy:

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: Gender Reassignment Surgery

Breast Reconstruction Policy:

The following procedures may be considered medically necessary when the above qualifications are met:

19324 Mammoplasty, augmentation; without prosthetic implant. Augmentation mammoplasty is only covered if there is inadequate breast enlargement after undergoing hormone treatment for at least 18 months and is not sufficient for comfort in the social role.

19325 Mammoplasty, augmentation; with prosthetic implant. Augmentation mammoplasty is only covered if there is inadequate breast enlargement after undergoing hormone treatment for at least 18 months and is not sufficient for comfort in the social role.

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

One referral from a qualified mental health professional is needed for breast/chest surgery (e.g., mastectomy, chest reconstruction, or augmentation mammoplasty).

Male to Female:

Criteria for breast augmentation (implants/lipofilling):

  1. Persistent, well-documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. 18 years of age (age of majority in the US. 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 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.

Policy: Gender Reassignment Surgery

Breast Reconstruction Policy:

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:

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