Premier Health Plan (Medicaid)

Policy Number
PA.205.PH
Policy Issued In
Ohio
Last Update
Breast Reconstruction

Premier Health Plan considers Gender Reassignment medically necessary for ALL of the following indications:

  1. The patient is at least 18 years old;
  2. The patient has the mental capacity for fully-informed consent
  3. The patient has been diagnosed with Gender Dysphoria (per the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) per the American Psychiatric Association, see definition in Background section) and therefore meets all the following indications:
    • The patient is participating in a recognized gender identity treatment group

    • The patient has the desire to live and be accepted as a member of the opposite sex

    • The transsexual identity of the patient has been present persistently for at least two years and is well-documented

    • Their gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning;

  4. The patient has undergone a minimum of 12 months of continuous hormonal therapy as appropriate to the patient’s gender goals (unless hormone therapy is contraindicated)
  5. The patient has completed 12 continuous months of living in the gender role that is congruent with their gender identity
  6. The patient has at least two referrals from qualified mental health professionals (see definition in Background section) who have independently assessed the patient

The following procedures may be considered cosmetic and therefore not medically necessary:

Breast Augmentation (unless for MtF when an appropriate trial of hormone therapy has not resulted in any breast enlargement)