Uniform Medical Plan Uniform Medical Plan (Washington State Health Care Authority)

Policy Number
54-0006
Policy Issued In
Washington
Last Update
Breast Reconstruction

A. Gender reassignment surgery (see UMP clinical criteria policy and Regence medical policy 153 guidelines) may be considered medically necessary in the treatment of gender dysphoria when all of the following criteria are met:

1. Age at least 18 years. For patients younger than 18 years of age, mastectomy may be considered a medically necessary surgical procedures. Other requirements outlined in this section must be met to proceed with mastectomy in those younger than 18 years of age.

2. Clinical records document that the patient has the capacity to make fully informed decisions and consent for treatment as part of a comprehensive, patient-centered treatment plan; and that any other mental health condition, if present, is adequately controlled; and

3. At least 2 licensed mental health professionals have diagnosed gender dysphoria, and recommend surgical treatment (*Only one mental health professional referral is required for mastectomy); and

a) Assesses the patient and makes or confirms the diagnosis of gender dysphoria as defined by the DSM-V criteria, and

b) Determines or confirms that the gender dysphoria is not due to another mental or physical health condition; and

4. Documentation of continuous hormonal therapy for at least 12 months, unless there is a documented medical contraindication to hormonal therapy. Hormonal therapy is not required prior to mastectomy; and

5. Twelve months of living in a gender role that is congruent with the patient’s gender identity.

Breast augmentation will require preauthorization with following criteria:

a) Documentation of continuous hormonal therapy for at least 12 months, unless there is documented medical contraindication to hormonal therapy; and

b) Have not reached a Tanner Stage 5.

Permanent Hair Removal

Genital electrolysis and laser hair removal as required as part of the genital surgery is covered with prior authorization and is limited to the genitals and, if applicable, the graft site, as required for genital surgery. Electrolysis and laser hair removal not meeting these guidelines and the guidelines for Surgical Treatments of Gender Dysphoria outlined in the Gender Affirming Interventions for Gender Dysphoria Criteria and Policy is not covered.

Youth Services

For patients younger than 18 years of age, mastectomy may be considered a medically necessary surgical procedures. Other requirements outlined in this section must be met to proceed with mastectomy in those younger than 18 years of age.