Medica

Policy Number
III-SUR.20
Policy Issued In
Minnesota
Last Update
Breast Reconstruction

Gender reassignment surgery is medically necessary when all of the following criteria are met (adapted from the World Professional Association for Transgender Health Inc., Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, (Seventh Version 2012):

A. The member must have a diagnosis of gender dysphoria from the Diagnostic and Statistical Manual of Mental Disorders [DSM 5-TR, 2013] section 302.6.

B. Eligibility criteria for specific surgeries:

1. Criteria for mastectomy for female to male

a. The member has persistent, well-documented gender dysphoria

b. The member is 18 years of age or older

c. The member has the capacity to make a fully informed decision and to consent for treatment

d. If significant medical or mental health concerns are present, documentation must support that they are reasonably well-controlled.

NOTE: Hormonal treatment is not a prerequisite for mastectomy.

2. Criteria for breast augmentation for male to female

a. The member has persistent, well-documented gender dysphoria

b. The member is 18 years of age or older

c. The member has the capacity to make a fully informed decision and to consent for treatment

d. If significant medical or mental health concerns are present, documentation must support that they are reasonably well-controlled

e. Twelve months of continuous hormonal gender reassignment treatment must be completed.