One comprehensive evaluation and recommendation within the last six months from a licensed mental health professional (see Guidelines below) AND
- Diagnosis of gender dysphoria (formerly gender identity disorder) confirmed by the evaluating mental health professional AND
- 18 years of age or older AND
- No medical contraindications to surgery
For augmentation mammaplasty for male to female patients, one of the following:
- failure of breast growth stimulation by estrogen (progression only to a young adolescent stage of development) OR
- emergence of serious or intolerable adverse effects during estrogen administration OR
- medical contraindication to use of estrogen OR
- risk-benefit analysis determined that surgery is preferable to estrogen therapy
Note: The criteria above apply for initial male to female augmentation mammaplasty, Additional breast augmentation after an initial augmentation mammaplasty is considered to be a feminization or cosmetic procedure, and therefore, member contract stipulations for feminization or cosmetic procedures (either contract exclusion or coverage criteria, whichever is applicable for the member’s health plan) apply.
Hair removal procedures (including electrolysis) may be considered medically necessary to treat tissue donor sites prior to phalloplasty or vaginoplasty.