Highmark Pennsylvania

Policy Number
S-184-008
Policy Issued In
Pennsylvania
Last Update
Breast Reconstruction

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