Independence Blue Cross (Medicare Advantage)

Policy Number
MA11.106d
Policy Issued In
Pennsylvania
Last Update
Breast Reconstruction

BREAST AUGMENTATION
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.