Health Net

Policy Number
HNCA.CP.MP.496
Policy Issued In
California
Last Update
Breast Reconstruction

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

Permanent Hair Removal

Medically Necessary/Reconstructive Surgery

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.

  • Electrolysis*
  • Hair transplantation
  • Hair removal

The above section clarifies how the plan administers benefits in accordance with the WPATH, SOC, Version 7. Provided a patient has been properly diagnosed with gender dysphoria or GID by a mental health professional or other provider type with appropriate training in behavioral health and competencies to conduct an assessment of gender dysphoria or GID, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy, certain options for social support and changes in gender expression are considered to help alleviate gender dysphoria or GID.

For example, with respect to hair removal through electrolysis, laser treatment, or waxing, the WPATH “Statement of Medical Necessity for Electrolysis” (July 15, 2016) clarifies that patients with the same condition do not always respond to, or thrive, following the application of identical treatments. Treatment must be individualized, such as with electrolysis, and medical necessity should be determined according to the judgment of a qualified mental health professional and the referring physician.

The documentation to support the medical necessity for hair removal should include all three essential elements:

  • A properly trained (in behavioral health) and competent (in assessment of gender dysphoria) professional has diagnosed the member with gender dysphoria or GID.
  • The individual has completed 3 years of feminizing hormonal therapy.
  • The medical necessity for electrolysis has been determined according to the judgment of a qualified mental health professional and the referring physician.

If any element remains to be satisfied before medical necessity can be determined, the individual should be directed to an appropriate network participating provider for consultation or treatment.

Facial Reconstruction

Medically Necessary/Reconstructive Surgery

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.

  • Blepharoplasty
  • Facial feminization
  • Facial bone reduction
  • Hair transplantation
  • Hair removal
  • Reduction thyroid chondroplasty
  • Rhinoplasty

The above section clarifies how the plan administers benefits in accordance with the WPATH, SOC, Version 7. Provided a patient has been properly diagnosed with gender dysphoria or GID by a mental health professional or other provider type with appropriate training in behavioral health and competencies to conduct an assessment of gender dysphoria or GID, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy, certain options for social support and changes in gender expression are considered to help alleviate gender dysphoria or GID.

Voice Therapy And Surgery

Medically Necessary/Reconstructive Surgery

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.

  • Voice modification surgery (see Section V)
Body Contouring

Medically Necessary/Reconstructive Surgery

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.

  • Abdominoplasty
  • Liposuction

The above section clarifies how the plan administers benefits in accordance with the WPATH, SOC, Version 7. Provided a patient has been properly diagnosed with gender dysphoria or GID by a mental health professional or other provider type with appropriate training in behavioral health and competencies to conduct an assessment of gender dysphoria or GID, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy, certain options for social support and changes in gender expression are considered to help alleviate gender dysphoria or GID.

Youth Services

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