Keystone First

Policy Number
17.03.01
Policy Issued In
Pennsylvania
Last Update
Breast Reconstruction

I. Criteria:

A. Member is an adult, age 18 years or older, or documented as an emancipated adolescent, or has documentation of appropriate consent from parent or guardian.

B. Member has the capacity to make fully informed decisions and consent for treatment.

C. Member has established diagnosis of persistent, well-documented Gender Confirmation Surgery (GCS) as defined in the DSM-5 TR criteria of GD in adolescents and adults: ...

The diagnosis has been made and documented by a professional appropriately trained in transgender medicine. (See glossary for definition of “appropriately trained in transgender medicine.”)

E. Member desires to live and be accepted as a person of the opposite sex, usually accompanied by the wish to make his/her body conform as much as possible with the preferred sex through surgery and hormone treatment.

F. Has had real-life experience of at least 12 months.

G. GD is not a symptom of another mental disorder.

II. Hormone therapy:

A. Member has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician with documentation of member’s compliance and the type, frequency and route of administration.

III. Psychotherapy:

A. Regular participation in psychotherapy throughout the real-life experience when recommended by a treating medical or mental health practitioner.

B. If significant medical or mental health issues are present, documentation is required indicating they are reasonably well controlled.

C. If the member is diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), documentation must indicate an effort has been made to improve these conditions with psychotropic medications and/or psychotherapy before GCS is considered.

IV. Referrals:

A. Three referrals are necessary:

1.One referral must be from the member’s medical provider or surgical provider who will be rendering longitudinal care.

2. Two referrals for genital surgery or one referral for breast or chest surgery; one of which must be from a qualified mental health professionals who has independently assessed the individual. (WPATH, p27)

3. If the first mental health referral is from the member’s psychotherapist, the second referral should be from an independent evaluator.

4. At least one of the mental health professionals submitting a letter must be appropriately trained in transgender medicine. (See glossary.)

The following surgeries required for male-to-female members are medically necessary if all the criteria listed in sections I. through V. are met:

1. Genital surgery and breast surgery: ... f. Mammaplasty, augmentation. g. Nipple/areola reconstruction.