Kaiser Permanente Northwest Region

Policy Number
UR 20.7
Last Update
Breast Reconstruction
  • This policy pertains to Washington PEBB members only effective 1/1/17.
  • OHP (Oregon Medicaid) see OHP Prioritized List, Guideline Note 127 for treatment of Gender Dysphoria.
  • For all other groups, breast augmentation is not covered. See UR 65 Transgender Surgery UM Criteria for covered gender transition procedures.

Breast augmentation will require prior-authorization utilizing the following coverage criteria

  1. Diagnosis of gender dysphoria (male to female) AND
  2. Has received at least 1 year of hormone therapy (unless there are contraindications) AND ONE:
    • No measurable cup size growth, defined as less than an A cup, in one or both breasts OR
    • Asymmetry where one breast did not have a measurable cup size growth, defined as less than an A cup.
  3. Documentation from surgeon of current cup size and proposed changes as well as photo documentation.