Requirements for breast augmentation for male-to-female members:
A. Single letter of referral from a qualified mental health professional; and
B. Persistent, well-documented gender dysphoria per DSM 5 Gender Dysphoria; and
C. Capacity to make a fully informed decision and to consent for treatment; and
D. Age 18 years or older (Note: age requirement will not be applied to augmentation in Male-to-Female patients if the surgeon, the primary care provider, and the qualified mental health professional unanimously document the medical necessity of earlier intervention)
E. If significant medical or mental health concerns are present, they must be reasonably well controlled. The health plan may require a second opinion regarding the patient’s stability prior to surgery if in question; and
F. Twelve months of living in a gender role that is congruent with their gender identity (real life experience) and
G. Twelve months of continuous hormone therapy as appropriate to the member’s gender goals.
If the referring medical provider or mental health provider requests surgical intervention prior to the patient’s completion of 12 months of hormone therapy and/or living in desired gender, the surgeon, the primary care provider, and the qualified mental health professional must submit evidence of medical necessity and clear rationale for the proposed surgical intervention to be done early. The three providers must submit written documentation to the plan that includes:
a. A comprehensive, coordinated treatment plan with evidence that all treatment plan criteria for surgery and treatment goals have been met; and
b. Clear rationale for the variation from either the 12-month period of hormone therapy and/or living for 12 months in desired gender; and
c. Patient understands the treatment plan, risks and benefits of surgery prior to completing the 12month period; and
d. The plan will determine authorization and consent to care based on medical necessity from the documentation outlined in A-G above.
The criteria above apply for only initial male to female augmentation mammaplasty, any additional breast augmentation after an initial mammaplasty is considered a cosmetic procedure, and therefore, a contract exclusion.
Requirements for facial hair removal
KP Washington will cover facial hair removal for members with documented gender dysphoria and who are transfeminine. The area of treatment is limited to the face and throat and excludes eyebrows. Member can have either electrolysis or laser hair removal or both. The member must work with the KP Transgender Case Manager to determine the best provider for the service and arrange for either insurance billing or member reimbursement for services. The member needs to have active status at the time of the service. Pt needs to be age 18 or older or have parental consent.
Unless there are medical contraindications to therapy, patients should undergo feminizing hormone therapy aimed at decreasing androgen effects prior to hair removal to enhance efficacy and prevent additional/recurrent terminal hair growth. Adequate androgen blockade can be demonstrated by ONE of the following:
a. 6 months or longer of medical therapy aimed at decreasing androgen production or effects (for example, spironolactone/ GNRH agonists/ finasteride with or without estrogen) OR
b. Serum testosterone (total) in the normal female range (<100mg/dL) OR
c. History of prior gonadectomy
Note: Patients who have not had gender reassignment surgery (gonadectomy or vaginoplasty) should continue hormone/anti-androgen therapy unless contraindicated during and after hair removal to prevent recurrence.