Horizon Blue Cross Blue Shield of New Jersey

Policy Number
115
Policy Issued In
New Jersey
Last Update
Breast Reconstruction

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.)

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.")