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Health Insurance Medical Policies - Youth Services


Below are excerpts from various health insurance medical policies that have explicit provisions detailing when treatments for gender dysphoria (such as puberty suppression or surgery) are covered for transgender people under 18.

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: Gonadotropin-Releasing Hormone Analogs and Antagonists

Youth Services:

Aetna considers leuprolide (Lupron, Viadur, Eligard) medically necessary for the following indications subject to the specified limitations:

  • To suppress onset of puberty in transgender adolescents if they meet WPATH criteria (see Appendix).
  • For female to male transgender persons, to stop menses prior to testosterone treatment and to reduce estrogens to levels found in biological males.
  • To reduce testosterone levels in male to female transgender persons.

Aetna considers histrelin acetate implants experimental and investigational for all other indications (e.g., precocious puberty due to adrenal hyperplasia, and suppression of onset of puberty in transgender adolescents) because there is insufficient evidence in the peer-reviewed literature.

Policy: Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indic…

Youth Services:

Gender Dysphoria in Adolescents

Medically Necessary:

  1. GnRH analogs are considered medically necessary for adolescents with gender dysphoria when all of the following criteria are met:
    1. Fulfills the DSM V criteria for gender dysphoria; and
    2. Has experienced puberty to at least Tanner stage 2; and
    3. Has (early) pubertal changes that have resulted in an increase of their gender dysphoria; and
    4. Does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment; and
    5. Has psychological and social support during treatment; and
    6. Demonstrates knowledge and understanding of the expected outcomes of GnRH analog treatment.

Not Medically Necessary:

GnRH analogs are considered not medically necessary for adolescents with gender dysphoria when the criteria above are not met.

Policy: Treatment of Gender Dysphoria

Youth Services:

Puberty Suppression Hormone Treatment: When benefits are provided under the member’s contract, JHHC will authorize puberty suppression hormone treatment for adolescents when ALL of the following criteria are met:

a. The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed), AND

b. Gender dysphoria emerged or worsened with the onset of puberty, AND

c. Any co-existing psychological, medical, or social problems that could interfere with treatment or compromise treatment adherence have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment, AND

d. The adolescents has the capacity to make fully informed decisions and has given informed consent. If the adolescent has not reached the age of medical consent, the parents or other legal caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.

Policy: Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)

Youth Services:

GENDER DYSPHORIA
Leuprolide acetate for injection is considered medically necessary and, therefore, covered for puberty suppression when all of the following criteria are met:

  • The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed), in accordance with criteria established in the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, [DSM-5].
  • Gender dysphoria emerged or worsened with the onset of puberty.
  • Puberty-suppressing hormones are recommended by a qualified professional provider who has consistently assessed the adolescent:
    • One referral letter and/or chart documentation for hormone therapy is required from a qualified professional provider.
  • If the adolescent has significant medical or mental health concerns, they are reasonably well controlled.
  • The individual has reached at least Tanner stage 2 of development.
Policy: Gonadotropin Releasing Hormone Analogs (GnRH)

Youth Services:

VI. Gender Dysphoria in Adolescents


A. GnRH analogs may be approved for adolescents (greater than or equal to 10 years of age and less than 18 years of age) with gender dysphoria when all of the following criteria are met:

1. Fulfills the DSMV criteria for gender dysphoria; and
2. Has experienced puberty to at least Tanner stage 2; and
3. Has (early) pubertal changes that have resulted in an increase of their gender dysphoria; and
4. Does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment; and
5. Has psychological and social support during treatment; and
6. Demonstrates knowledge and understanding of the expected outcomes of GnRH analog treatment.

May NOT be approved:
GnRH analogs may NOT be approved for adolescents with gender dysphoria when the criteria above are not met.

Policy: Transgender Services

Youth Services:

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

No age restriction on hormones.

Policy: Gonadotropin Releasing Hormone Analogs and Antagonists

Youth Services:

Has coverage criteria for Leuprolide acetate suspension for intramuscular depot administration in children (Lupron Depo-Ped) and Histrelin acetate subcutaneus implant (Vantas and Supprelin)

Policy: Gender Reassignment Surgery Policy

Youth Services:

There is no minimum age requirement listed for coverage.

Policy: GnRH Gender Dysphoria

Youth Services:

Off Label Use: GnRH analogues can be used in the treatment of Gender Dysphoria (GD) and should only be started once a diagnosis of GD or transsexualism has been made per the DSM V or ICD-10 criteria (1).

For Gender Dysphoria (GD):

MUST HAVE ALL of the following:

  1. Prescribed by an endocrinologist or transgender specialist
  2. Patient has met the DSM V criteria for GD
Policy: Treatments for Gender Dysphoria

Youth Services:

Hormone Therapy for Adolescents: Endocrine Society Clinical Practice Guidelines for endocrine treatment of transsexual persons state that adolescents are eligible and ready for gonadotropin-releasing hormone (GnRH) therapy for suppression of puberty if they:

  1. Fulfill DSM IV-TR or ICD-10 criteria for gender identity disorder (GID) or transsexualism
  2. Have experienced puberty to at least Tanner stage 2
  3. Have (early) pubertal changes that have resulted in an increase of their gender dysphoria
  4. Do not suffer from psychiatric comorbidity that interferes with the diagnostic work-up or treatment
  5. Have adequate psychological and social support during treatment
  6. Demonstrate knowledge and understanding of the expected outcomes of GnRH analog treatment, cross-sex hormone treatment, and sex reassignment surgery, as well as the medical and the social risks and benefits of sex reassignment
Policy: Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indic…

Youth Services:

  1. GnRH analogs are considered medically necessary for adolescents with gender dysphoria when all of the following criteria are met: 
    1. Fulfills the DSM V criteria for gender dysphoria; and 
    2. Has experienced puberty to at least Tanner stage 2; and 
    3. Has (early) pubertal changes that have resulted in an increase of their gender dysphoria; and 
    4. Does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment; and 
    5. Has psychological and social support during treatment; and 
    6. Demonstrates knowledge and understanding of the expected outcomes of GnRH analog treatment.
Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Youth Services:

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

  • Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);
  • Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or
  • Chest surgery for FtM individuals.
Policy: Treatment of Gender Dysphoria

Youth Services:

Gender reassignment surgery may be considered medically necessary when ALL of the following criteria are met:  Age of majority in a given country. Note: WPATH guidelines address age of majority in a given country. For the purposes of this guideline, the age of majority is age 18. However, this refers to chronological age not biological age. Where approval or denial of benefits is based solely on the age of the individual a case-by-case medical director review is necessary.

Policy: Gender Affirming Services (Transgender Services)

Youth Services:

Puberty Blockers

Gonadotropin-releasing hormone (GnRH) analog treatment for gender non-conforming adolescents seeking to delay puberty is covered at the discretion of the treating provider*. GnRH analogs may be used to either allow patients more time for decision making purposes or as an initial step prior to further gender affirming services such as hormone replacement.

Treatment options include but are not limited to:

  • Lupron
  • Supprelin LA
  • Vantas
  • Triptodur (triptorelin).

Surgical Services for Adolescents

Members < 18 years of age will be considered on a case-by-case basis.

In addition to meeting all of the above criteria, providers requesting surgery for members < 18 will need to provide documentation supporting all of the following:

  • The member has been evaluated for safety.
  • The member has adequate home support.
  • The member has realistic expectations regarding the possibilities and limitations of surgery and a full understanding of the long-term consequences of surgical procedures.
  • The member has been assessed for any co-existing mental health concerns and is not requesting surgery as an initial response to gender dysphoric puberty.
Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Youth Services:

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

• Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);

• Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or

• Chest surgery for FtM individuals.

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

Youth Services:

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

  • Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);
  • Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or
  • Chest surgery for FtM individuals.
Policy: Gender Confirmation Surgery and Hormone Therapy

Youth Services:

For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is (Note: for those candidates requesting female to male surgery see item 4. below): For candidates requesting female to male surgery only: a. When the initial requested surgery is solely a mastectomy, the treating physician may indicate that no hormonal treatment (as described in criteria 3. above) is required prior to performance of the mastectomy. In this case, the 12 month requirement for hormonal treatment will be waived only when all other criteria contained in this policy and in the member’s health benefit plan are met.  

Gender confirmation surgery is rarely appropriate for patients under the age of 18. Requests for mastectomy for female to male transgender individuals age 17 or older may be considered only in exceptional circumstances on an individual consideration basis.

Criteria for Adolescents Entering Puberty

Adolescents, having reached puberty (tanner 2), and who have met eligibility and readiness criteria can be treated with GnRH analogues.

The definition of puberty is having reached Tanner stage 2/5 and/or having LH, estradiol levels or testosterone levels, within the pubertal range. These LH, estradiol and testosterone ranges are well-known and published and are broken down by biological male vs. biological female Tanner stage, and nocturnal and diurnal levels.

Adolescents are eligible for GnRH treatment, (for suppression of puberty) by these eligibility criteria: (same for adults)

  1. Have an established diagnosis for GID or transsexualism based on DSM V or ICD-10 criteria;
  2. Have experienced puberty to at least Tanner stage 2, which can be confirmed by pubertal levels of LH, estrogen or testosterone;
  3. Have experienced pubertal changes that resulted in an increase of their gender dysphoria;
  4. Do not suffer from psychiatric comorbidity (that interferes with the diagnostic work-up or treatment);
  5. Have adequate psychological and social support during treatment, to include having parental/guardian consent;
  6. Demonstrate knowledge and understanding of the expected outcomes of GnRH analogue treatment, cross-sex hormone treatment, and gender confirmation surgeries, as well as the medical and social risks and benefits of gender reassignment; and have been counseled regarding fertility options.
Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Youth Services:

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

  • Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);
  • Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or
  • Chest surgery for FtM individuals.
Policy: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Youth Services:

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

  • Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);
  • Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or
  • Chest surgery for FtM individuals.
Policy: Gender Reassignment Surgery for Gender Identity Disorder

Youth Services:

Initiation of feminizing/masculinizing hormone therapy, preferably for members under the age of 18 with parental or legal guardian consent, may be provided after a psychosocial assessment has been conducted and informed consent has been obtained by a health professional.

Policy: Gonadotropin-releasing Hormone Agonists

Youth Services:

Coverage for Lupron Depot®/Lupron Depot Ped® is provided for treatment of the following conditions:

  • Gender dysphoria
    • The diagnosis of gender dysphoria and the referral for hormone therapy have been made by a mental health professional in accordance with the WPATH criteria AND
    • The patient must be followed by an endocrinologist AND
    • If used for suppression of puberty, therapy should not be started earlier than Tanner stage 2
Policy: GnRH Agents

Youth Services:

Adolescents are eligible and ready for GnRH treatment if they:

  1. Fulfill DSM IV-TR or ICD-10 criteria for GID or transsexualism.
  2. Have experienced puberty to at least Tanner stage 2.
  3. Have (early) pubertal changes that have resulted in an increase of their gender dysphoria.
  4. Do not suffer from psychiatric comorbidity that interferes with the diagnostic work-up or treatment.
  5. Have adequate psychological and social support during treatment, AND
  6. Demonstrate knowledge and understanding of the expected outcomes of GnRH analog treatment, cross-sex hormone treatment, and sex reassignment surgery, as well as the medical and the social risks and benefits of sex reassignment.

Note: Readiness criteria for adolescents eligible for cross-sex hormone treatment are the same as those for adults.

Policy: Gender Affirmation Surgeries

Youth Services:

Note: Plan Medical Director review is required for any gender affirmation surgery for a member less than age 18 on the date of service. Requests for surgical treatment will be reviewed based on the Plan’s Medically Necessary medical policy, policy number OCA 3.14, and the current version of the WPATH Standards of Care for Health and Transsexual, Transgender, and Gender-Nonconforming People. In addition, the Plan Medical Director will review the member’s clinical situation, including but not limited to the amount of time the adolescent member has been living in the desired gender role, treatment timeframe with hormone therapy, age of the member, and the requested intervention. Adolescent members may be eligible for interventions when adolescents and their parents (or guardian) make informed decisions about treatment, and the service is a covered benefit for the Plan member. Informed consent by a parent or guardian for treatment of an adolescent member may not apply if the adolescent member is emancipated at the time the service is rendered (as determined by state requirements).

Policy: Gender Affirming Interventions for Gender Dysphoria

Youth Services:

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

Policy: Gender Reassignment Surgery for Gender Dysphoria

Youth Services:

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.

Policy: Gender Reassignment Services

Youth Services:

Hormone therapy for individuals under the age of 18:

  • For those without a medical contraindication to hormonal therapy, authorization of 12 months of hormone therapy is considered medically necessary for young adolescents with a diagnosis of gender dysphoria who are prescribed hormone therapy when ALL of the following criteria are met:
  • Hormone therapy is prescribed for pubertal suppression for the treatment of gender dysphoria; and The individual has reached at least Tanner stage 2 of puberty.
  • Authorization of for continuation therapy must meet ALL initial authorization criteria.

Refer to CVS Caremark Specialty Guideline Management: Lupron Depot-PED and WPATH criteria Section VI.

Policy: Treatment of Gender Dysphoria

Youth Services:

Adolescents: Puberty-suppressing hormones (e.g., GnRH analogues) for adolescents may be provided to individuals who have reached at least Tanner stage 2 of sexual development. The Endocrine Society supports puberty suppression and has developed criteria for a subset of individuals who fulfill and meet eligibility readiness for gender reassignment (Hembree, et al., 2009). WPATH clinical recommendations also support puberty suppression (WPATH, 2012) for a similar subset of individuals. Consistent with adult hormone therapy, treatment of adolescents involves a multidisciplinary team, however when treating an adolescent a pediatric endocrinologist should be included as a part of the team. Pre-pubertal hormone suppression differs from hormone therapy used in adults and may not be without consequence; some pharmaceutical agents may cause negative physical side effects (e.g., height, bone growth).

Policy: Histrelin acetate subcutaneous implant

Youth Services:

Cigna covers histrelin acetate (Supprelin LA) subcutaneous implant as medically necessary for suppression of puberty in adolescents with gender dysphoria when ALL of the following criteria are met:

  • Documented diagnosis of gender dysphoria or gender identity disorder fulfilling the Diagnostic and th Statistical Manual of Mental Disorders, 5 edition (DSM-V) criteria or International Classification of Diseases 10 (ICD-10) criteria
  • Reached at least Tanner stage 2 of puberty
  • Gender dysphoria has emerged or worsened with the onset of puberty.
  • Absence of psychiatric comorbidity that would interfere with diagnosis or treatment
  • Individual will have psychological and social support during treatment.
  • Demonstrated knowledge and understanding of the expected outcomes of histrelin acetate (Supprelin LA) treatment
Policy: Gonadotropin-Releasing Hormones (prior authorization policy)

Youth Services:

Off Label Use: GnRH analogues can be used in the treatment of Gender Dysphoria (GD) and should only be started once a diagnosis of GD or transsexualism has been made per the DSM V or ICD-10 criteria (1).

Policy: Gender Affirming/Reassignment Surgery — New York

Youth Services:

  1. Treatment with gonadotropin-releasing hormone agents (pubertal suppressants) when based upon a determination by a qualified medical professional that the member is eligible and ready for such treatment, i.e., that the member: a. Meets gender dysphoria diagnostic criteria b. Has experienced puberty to at least Tanner stage 2 with pubertal changes resulting in increased gender dysphoria c. Does not suffer from psychiatric comorbidity that interferes with diagnostic work-up or treatment d. Has adequate psychological and social support during treatment e. Demonstrates knowledge and understanding of expected treatment-outcomes associated with pubertal suppressants and cross-sex hormones, as well as the medical and social risks and benefits of sex reassignment
  2. Treatment with cross-sex hormones for members ≥ 16 years of age when based upon a determination of medical necessity made by a qualified medical professional. (Members < 18 years of age must meet Criteria # 1).

Note: Requests for coverage of cross-sex hormones for members less than 16 years of age will be reviewed on a case-by-case basis.

Requests for gender reassignment surgery for members less than 18 years will be reviewed on a case-by-case basis.

Policy: Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indic…

Youth Services:

GnRH analogs are considered medically necessary for adolescents with gender dysphoria when all of the following criteria are met:

  1. Fulfills the DSM V criteria for gender dysphoria; and
  2. Has experienced puberty to at least Tanner stage 2; and
  3. Has (early) pubertal changes that have resulted in an increase of their gender dysphoria; and
  4. Does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment; and
  5. Has psychological and social support during treatment; and
  6. Demonstrates knowledge and understanding of the expected outcomes of GnRH analog treatment.
Policy: Testosterone Injectable

Youth Services:

Testosterone injection are considered medically necessary for transgender individuals who meet ALL the following criteria:

  1. Individual is 16 years of age or older; and
  2. Individual has a diagnosis of gender dysphoria/incongruence or gender identity disorder; and
  3. The goal of treatment is female-to-male gender reassignment.
Policy: Subcutaneous Hormone Replacement Implants

Youth Services:

  1. Subcutaneous testosterone implants are considered medically necessary for transgender individuals when ALL of the following criteria are met (A, B and C): 
    1. Individual is 16 years of age or older; and
    2. Individual has a diagnosis of gender dysphoria/incongruence or gender identity disorder; and
    3. The goal of treatment is female-to-male gender reassignment.
Policy: Transgender Services

Youth Services:

Puberty Suppression Hormone Therapy:

Adolescents with gender non-conformity or diagnosed gender dysphoria often begin hormone therapy at the onset of puberty. Given puberty suppression is reversible it allows an adolescent the ability to fully explore their gender non-conformity and make informed decisions regarding future treatment. Puberty Suppression hormone treatments are overseen by a Pediatric Endocrinologist and often a Mental Health professional.

In accordance with WPATH the below minimal criteria must be met

1. The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed);

2. Gender dysphoria emerged or worsened with the onset of puberty;

3. Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment;

4. The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.

Policy: Gender Transition Services

Youth Services:

Puberty-suppressing hormones in adolescents criteria

  • The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed); AND
  • Gender dysphoria emerged or worsened with the onset of puberty; AND
  • Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment; AND
  • The adolescent has been given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.
  • Initiation of hormone therapy is recommended by a qualified health professional with written documentation; AND
  • Laboratory testing to monitor the safety of continuous hormone therapy; AND
  • Hormonal treatment can occur before the age of 18 after discontinuation of pituitary-blocking agents.
Policy: Gender Dysphoria and Gender Confirmation Treatment

Youth Services:

Peri-pubertal – gonadotropin-releasing hormone (GnRH) analogs to achieve suppression of pubertal hormones may be considered once the member reaches Tanner Stage* 2

*The Tanner Scale is measurement of physical development in children, adolescents and adults.

http://www.childgrowthfoundation.org/CMS/FILES/Puberty_and_the_Tanner_Stages.pdf

• Between 14 – 16 yrs of age –pubertal development of the desired opposite sex can be using a gradually increasing dose schedule of cross-gender hormone.

• Adolescents should be treated with GnRH analogues, progestins (e.g., medroxyprogesterone) or other medications that block and/or neutralize testosterone, estrogens and progesterone secretion.

Surgical Treatment

Per WPATH guidelines, “Chest surgery in FtM patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression.”

Policy: Transgender Health Services

Youth Services:

Consideration for breast and chest surgery (e.g. nipple areola reconstruction, mastectomy, breast augmentation) will be given to trans-adolescents under the age of 18 who meet all other policy criteria (e.g. hormone therapy).

Policy: Gender Reassignment Surgery

Youth Services:

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

Policy: Gender Reassignment Surgery

Youth Services:

  1. All of the following criteria must be met prior to mastectomy for female to male members:
    1. The member must: ... Be at least 18 years old, the legal age of majority in Minnesota; however, approval of this surgery for members less than 18 years old will be considered on a case-by-case basis where consistent with WPATH SOC-7 guidelines relating to treatment of children and adolescents; and
Policy: Testosterone Androgens

Youth Services:

Testosterone injections may be considered medically necessary for transgender individuals who meet ALL the following:

  • Individual is 16 years of age or older; and
  • Individual has a diagnosis of gender dysphoria or gender identity disorder; and
  • The goal of treatment is female-to-male gender reassignment.
Policy: Gender Identity Services

Youth Services:

Puberty suppression therapy is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

  1. The patient has been diagnosed with persistent, well-documented gender dysphoria as defined by the current Diagnostic and Statistical Manual of Mental Disorders(DSM) criteria (see Appendix B) and gender identity disorder as defined by the current International Classification of Diseases(ICD) criteria by a qualified mental health professional (see Appendix A);
  2. The patient has exhibited the first physical changes of puberty, indicated by a minimum Tanner stage of 2;
  3. The patient has completed at least three months of successful continuous full time real-life experience in their gender identity across a wide span of life experiences and events (e.g., holidays, vacations, season-specific school and/or work experience, family events);
  4. Clinical records document that the patient assents to treatment and the parent/guardian has made a fully informed decision and consent to treatment;
  5. The patient’s comorbid medical and mental health conditions(if present) are reasonably well-controlled; and
  6. Puberty suppression therapy will be administered in a safe, appropriate, medically supervised manner.

Continuous hormone replacement therapy is covered ... when ... the patient is at least 16 years of age; if the candidate is less than 16 years of age, then treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet this criterion.

Breast/chest surgery: subcutaneous mastectomy, creation of a male chest; including nipple reconstruction (if appropriate) is covered (subject to Limitations and Administrative Guidelines) when ... the patient is at least 16 years of age; if the candidate is less than 16 years of age, then treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet this criterion.

Policy: Gender Reassignment Surgery

Youth Services:

For mastectomy: 

For members younger than 18 years of age, please see NOTE below;

(NOTEHormone therapy is not a pre-requisite.

According to the WPATH Standards of Care 7th Edition, "Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression.")

Policy: Drug Therapy for Transgender Policy

Youth Services:

Coverage for GnRH and/or hormone therapy for adolescents is considered medical necessary for:

  • A. GnRH use in Gender Dysphoria, when ALL of the following criteria are met:
    • 1. Fulfills the DSM V or ICD-10 criteria for gender dysphoria; and
      2. Has experienced puberty to at least Tanner stage 2; and
      3. Has (early) pubertal changes that have resulted in an increase of their gender dysphoria; and
      4. Does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment or mental health comorbidities must be reasonably well-controlled; and
      5. Has adequate psychological and social support during treatment; and
      6. Has the capacity to make a fully-informed decision and to consent to treatment; and 
      7. Demonstrates knowledge and understanding of the expected outcomes of GnRH treatment, as well as the medical and social risks and benefits.
      B. Cross-sex hormone treatment (testosterone or estrogen) in adolescents are eligible for if they:
      • 1. Fulfill the criteria for GnRH treatment, and
        2. Are 16 years or older.
    Policy: Gender Reassignment Services

    Youth Services:

    Puberty Suppressing Hormone Therapy:

    Puberty-suppressing hormones may be appropriate in adolescents as soon as pubertal changes have begun. In order for adolescents and their parents to make an informed decision about pubertal delay, it is recommended that adolescents experience the onset of puberty to at least Tanner Stage 2. The use of puberty – suppressing hormones:

    • May give adolescents more time to explore their gender nonconformity and other developmental issues; and
    • May facilitate transition by preventing the development of sex characteristics that are difficult or impossible to reverse if adolescents continue on to pursue gender affirmation surgery.

    Puberty suppression may continue for a few years, at which time a decision is made to either discontinue all hormone therapy or transition to a feminizing/masculinizing hormone regimen.

    Feminizing/Masculinizing Hormone Therapy Feminizing/masculinizing hormone therapy may be appropriate, Ideal treatment would be after evaluation by, or under the supervision of, a clinician with knowledge in bone development, e.g. pediatrician or pediatric endocrinologist. Treatment decisions should involve the adolescent, the family, and the treatment team.

    EPSDT Special Provision Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a federal Medicaid requirement that requires the Connecticut Medical Assistance Program (CMAP) to cover services, products, or procedures for Medicaid enrollees under 21 years of age where the service or good is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition identified through a screening examination. The applicable definition of medical necessity is set forth in Conn. Gen. Stat. Section 17b-259b (2011) [ref. CMAP Provider Bulletin PB 2011-36].

    Policy: Treatment of Gender Dysphoria

    Youth Services:

    PUBERTY SUPPRESSING HORMONES
    Puberty suppressing hormones (e.g., Supprelin LA® [histrelin acetate], Vantas® [histerlin acetate], Lupron Depot® [leuprolide acetate for depot suspension] , Viadur® [leuprolide acetate implant], Eligard® [(leuprolide acetate for injectable suspension], Zoladex® [goserelin acetate implant], Trelstar® [triptorelin pamoate for injectable suspension]) are considered medically necessary, and therefore covered, when all of the following criteria are met:

    • The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed), in accordance with criteria established in the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, [DSM-5]
    • The individual has reached at least Tanner Stage 2 of development
    • Gender dysphoria emerged or worsened with the onset of puberty
    • Puberty suppressing hormones are recommended by a qualified professional provider who has consistently assessed the adolescent
      • One referral letter and/or chart documentation for hormone therapy is required from a qualified professional provider
    • If the adolescent has significant medical or mental health concerns, they are reasonably well controlled

    Note: Subject to the terms, conditions, and limitations of the member’s contract, oral and self-administered hormones are not covered under the medical benefit.

    CONTINUOUS HORMONE REPLACEMENT THERAPY
    Continuous hormone replacement therapy (e.g., testosterone enanthate, testosterone pellet, estradiol valerate or medroxyprogesterone acetate) for the treatment of gender dysphoria, is considered medically necessary, and therefore, covered when all of the following criteria are met:

    • The individual has persistent, well documented gender dysphoria diagnosed in accordance with the criteria established in the Diagnostic and Statistical Manual of Mental Disorders – Fifth edition [DSM-5]
    • Continuous hormone replacement therapy is recommended by a qualified professional provider who has consistently assessed the individual
      • One referral letter and/or chart documentation for hormone therapy is required from a qualified professional provider
    • If the individual has significant medical or mental health concerns, they are reasonably well controlled


    Note: Subject to the terms, conditions, and limitations of the member’s contract, oral and self-administered hormones are not covered under the medical benefit.

    Policy: Gender Affirmation Treatment & Procedures

    Youth Services:

    Hormones under 18: For individuals under the age of 18, screening for the presence of the diagnosis of Gender Dysphoria and for medical and mental health issues must be completed by two qualified health professionals, one of whom must be a physician.

    Policy: Transgender Surgery

    Youth Services:

    For FtM members under the age of 18, chest surgery can be carried out on adolescents 16 years or older after ample time of living in the desired gender role and after one year of testosterone treatment. Adolescent FtM patients seeking chest surgery must also meet criteria 2-6 above and must have parental consent or be legally emancipated.

    Policy: Leuprolide long-acting

    Youth Services:

    Approve Lupron Depot, Eligard, or Lupron Depot-Ped for 1 year if prescribed by or in consultation with an endocrinologist or a physician who specializes in the treatment of transgender patients.

    The Endocrine Society guideline (2009) for treatment of transsexual persons recommends that adolescents who fulfill eligibility criteria for gender reassignment initially undergo treatment to suppress pubertal development. 12 The guidelines recommend that suppression of pubertal hormones start when girls and boys first exihibit physical changes of puberty, but no earlier than Tanner stages 2 to 3 (early puberty). According to the guidelines, suppression of pubertal development and gonadal function is most effectively accomplished by GnRH analogs and antagonists. However, since no long-acting GnRH antagonists are available, long-acting analogs are the currently preferred treatment option. An advantage of GnRH therapy is noted to be its reversibility; pubertal suppression can be discontinued and spontaneous pubertal development will resume immediately after stopping GnRH analog therapy. The World Professional Association for Transgender Health (WPATH) Standards of Care (version 7) document also recommends the use of GnRH analogs in both male and female adolescents as a fully reversible intervention for pubertal suppression. 13 Although too late to block endogenous pubertal development, GnRH analogs can also be used in late pubertal patients to suppress the hypothalamic-pituitary-gonadal axis, potentially allowing for lower doses of cross-sex hormones. 14 In addition to use in adolescents, GnRH analog therapy is also used in adults, particularly MTF patients. 15 In the professional opinion of a practicing specialist physician reviewing the available guidelines, we have adopted this criterion.

    Policy: Gender Reassignment Surgery

    Youth Services:

    Reversible therapy with puberty-suppressing hormones are medically appropriate with ALL of the following:

    1. The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed)
    2. Gender dysphoria emerged or worsened with the onset of puberty
    3. The member has experienced the onset of puberty to at least Tanner Stage 2.
    4. Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g. may compromise adherence with treatment) have been addressed such that the adolescent’s situation and functioning are stable enough to start treatment
    5. The adolescent has given informed consent, and particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.

    Chest surgery in FtM adolescent patients may be carried out prior to 18 with ALL of the following:

    1. Meets all of the criteria for treatment of adolescent with puberty-suppressing hormones and masculinizing hormones
    2. Reached the age of medical consent
    3. Had ample time (preferably one year) living in the desired gender role
    4. Undergone one year of testosterone treatment.
    Policy: Gender Dysphoria Treatment

    Youth Services:

    No authorization is required for behavioral and medical health.

    Requires Authorization:

    Services for Members Less than 18 Years of Age:

    1. Pharmacological and hormonal therapy that is non-reversible and/or produces masculinization or feminization
    2. Pharmacological and hormonal therapy to delay physical changes of puberty
    Policy: Sex Reassignment Surgery (Gender Affirmation Surgery)

    Youth Services:

    Non-surgical services are covered with sex reassignment surgery when the aforementioned criteria are

    met; covered services include: ... Gonadotropin-releasing hormone to suppress puberty in trans-identified adolescents.

    Policy: Gonadotropin Releasing Hormone Analogs

    Youth Services:

    Gender Dysphoria in Adolescents:

    GnRH analogs may be covered for the treatment of Gender Dysphoria when ALL of the following criteria are met:

    For initial therapy, submission of medical records (e.g., chart notes, laboratory values) documenting all the following:

    • Diagnosis of gender dysphoria, according to the current DSM (i.e., DSM-5) criteria, by a mental health professional with expertise in child and adolescent psychiatry; and
    • Medication is prescribed by or in consultation with a pediatric endocrinologist or by a physician working in a multidisciplinary clinic for transgender youth; and
    • Patient has experienced puberty development to at least Tanner stage 2 (stage 2 through 4); and
    • One of the following laboratory tests, based upon the laboratory reference range, confirming:
      • Pubertal levels of estradiol in females; or
      • Pubertal levels of testosterone in males; or
      • Pubertal basal level of luteinizing hormone (based on laboratory reference ranges); or
      • A pubertal luteinizing hormone response to a GnRH stimulation test; and
      • A letter from the prescriber and/or formal documentation stating all of the following:
        • Patient has experienced pubertal changes that have resulted in an increase of their gender dysphoria that has significantly impaired psychological or social functioning; and
        • Coexisting psychiatric and medical comorbidities or social problems, that may interfere with the diagnostic
        • procedures or treatment, have been addressed or removed; and
        • Both of the following:
          • Current enrollment, attendance, and active participation in psychological and social support treatment program; and
          • Patient will continue enrollment, attendance and active participation in psychological and social support throughout the course of treatment; and
        • Patient demonstrates knowledge and understanding of the expected outcomes of treatment and related transgender therapies; and
        • Initial authorization will be for no longer than 12 months.

    For continuation therapy, submission of medical records (e.g., chart notes, laboratory values) documenting all the following:

    • Documentation of LH suppression using a GnRH stimulation test
    • Documented diagnosis of gender dysphoria, according to the current DSM (i.e., DSM-5) criteria, by a mental health professional with expertise in child and adolescent psychiatry; and
    • Medication is prescribed by or in consultation with a pediatric endocrinologist or by a physician working in a multidisciplinary clinic for transgender youth; and
    • A letter from the prescriber and/or formal documentation stating all of the following:
      • Patient continues to meet their individual goals of therapy for gender dysphoria; and
      • Patient continues to have a strong affinity for the desired (opposite of natal) gender; and
      • Discontinuation of treatment and subsequent pubertal development would interfere with or impair psychological functioning and well-being; and
      • Coexisting psychiatric and medical comorbidities or social problems that may interfere with treatment continue to be addressed or removed; and
      • Both of the following:
        • Current enrollment, attendance, and active participation in psychological and social support treatment program; and
        • Patient will continue enrollment, attendance and active participation in psychological and social support throughout the course of treatment and
    • Patient demonstrates knowledge and understanding of the expected outcomes of treatment and related transgender therapies; and
    • Reauthorization will be for no longer than 12 months.

    Note: Clinical evidence supporting the use of GnRH analogs for the treatment of gender dysphoria is limited and lacks long-term safety data. Statistically robust randomized controlled trials are needed to address the issue of whether the benefits outweigh the clinical risk in its use.

    Policy: Prior Authorization/Medical Necessity – Topical Androgens

    Youth Services:

    No age restriction for testosterone.

    Policy: Gender dysphoria

    Youth Services:

    Adolescents. Various hormones can be given to members not of majority age undergoing gender transformation. Similar to adults, the specific hormones vary by individual, but often serve to suppress puberty in the member’s birth gender. All cases must observe the following criteria:

    1. The member has a long-lasting and intense pattern of gender nonconformity or dysphoria.
    2. Gender dysphoria emerged or worsened with the onset of puberty.
    3. Any co-existing psychological, social, or medical problems that could interfere with treatment have been addressed, and the member’s condition is stable.
    4. The member has given informed consent, or (if not of age) parents, other caretakers, or guardians have consented to treatment and are involved in the treatment process.
    Policy: Gender Affirming Interventions for Gender Dysphoria

    Youth Services:

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

    Policy: Medical Necessity Guidelines: Transgender Surgical Procedures

    Youth Services:

    No age requirement listed for surgery.

    Policy: Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indic…

    Youth Services:

    Gender Dysphoria in Adolescents

    Medically Necessary:

    1. GnRH analogs are considered medically necessary for adolescents with gender dysphoria when all of the following criteria are met: 
      1. Fulfills the DSM V criteria for gender dysphoria; and
      2. Has experienced puberty to at least Tanner stage 2; and
      3. Has (early) pubertal changes that have resulted in an increase of their gender dysphoria; and
      4. Does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment; and
      5. Has psychological and social support during treatment; and
      6. Demonstrates knowledge and understanding of the expected outcomes of GnRH analog treatment.

    Not Medically Necessary:

    GnRH analogs are considered not medically necessary for adolescents with gender dysphoria when the criteria above are not met.

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

    Youth Services:

    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.

    Policy: Gonadotropin Releasing Hormone Analogs

    Youth Services:

    GnRH analogs may be covered for the treatment of Gender Dysphoria when all of the following criteria are met [see document]

    Policy: Gender Dysphoria (Gender Identity Disorder) Treatment

    Youth Services:

    Note: WPATH guidelines address age of majority in a given country. For the purposes of this guideline, the age of majority is age 18. However, this refers to chronological age and not biological age. Where approval or denial of benefits is based solely on the age of the individual a case-by-case medical director review is necessary.

    Policy: Gender Dysphoria Treatment Excluding California

    Youth Services:

    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

    Youth Services:

    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

    Youth Services:

    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

    Youth Services:

    Puberty suppression therapy is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

    1. The patient has been diagnosed with persistent, well-documented gender dysphoria as defined by the current Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria (see Appendix B) and gender identity disorder as defined by the current International Classification of Diseases (ICD) criteria by a qualified mental health professional (see Appendix A);
    2. The patient has exhibited the first physical changes of puberty, indicated by a minimum Tanner stage of 2 or 3;
    3. The patient has completed at least three months of successful continuous full time real-life experience in their gender identity across a wide span of life experiences and events (e.g., holidays, vacations, season-specific school and/or work experience, family events);
    4. Clinical records document that the patient assents to treatment and the parent/guardian has made a fully informed decision and consents to treatment;
    5. The patient’s comorbid medical and mental health conditions (if present) are reasonably well-controlled; and
    6. Puberty suppression therapy will be administered in a safe, appropriate, medically supervised manner.

    Continuous hormone replacement therapy is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

    1. The patient is at least 16 years of age;

    Policy: Gender Confirmation

    Youth Services:

    Minimum 18 years of age or on a case by case basis, the minimum age of 18 years may be reconsidered for mastectomy surgeries if sufficient documentation is provided, all other criteria have been met, and the presence of the breasts precludes the patient from successfully adopting a male or androgynous gender role.

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

    Policy: Gender Reassignment Surgery

    Youth Services:

    Gonadotropin-releasing hormone is considered medically necessary to suppress puberty in trans identified adolescents if they meet World Professional Association for Transgender Health (WPATH) criteria:

    • Adolescent has demonstrated a long-lasting and intense pattern of gender non-conformity or gender dysphoria (whether suppressed or expressed); AND
    • Gender dysphoria emerged or worsened with the onset of puberty; AND
    • Any co-existing psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment; AND
    • Adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.
    Policy: Testosterone – Topical/Buccal/Nasal

    Youth Services:

    The requested drug is being prescribed for female-to-male gender reassignment in a patient who is 14 years of age or older and able to make an informed, mature decision to engage in therapy

    Policy: Testosterone – Topical/Buccal/Nasal/Oral

    Youth Services:

    • The requested drug is being prescribed for female-to-male gender reassignment
    • The member is 14 years of age or older and able to make an informed, mature decision to engage in therapy
    Policy: Gender Reassignment Surgery

    Youth Services:

    Although the minimum age for Medicaid coverage of gender reassignment surgery is generally 18 years of age, the revised regulations allow for coverage for individuals under 18 in specific cases if medical necessity is demonstrated and prior approval is received.