UnitedHealthcare West (California)

Policy Number
BIP185.I
Policy Issued In
California
Last Update
Breast Reconstruction

Surgical treatment for Gender Dysphoria is covered when the Eligibility Qualifications for Surgery are met:

2. Surgery to change specified secondary sex characteristics, specifically:

Augmentation mammoplasty (including breast prosthesis if necessary) if the Physician prescribing hormones and the surgeon have documented that breast enlargement after undergoing hormone treatment for 18 months is not sufficient for comfort in the social role.

Clarifications for breast/chest surgery:

In addition to the Eligibility Qualifications listed above note the following:

A biologic male member that is only requesting a breast augmentation:

  • If able to take female hormones, the member should take the female hormones for at least 12-24 months* before being considered for bilateral breast augmentation since the member may achieve adequate breast development without surgery.
  • Although not a requirement for coverage, UnitedHealthcare recommends that the member complete at least 3 months of psychotherapy before having the breast augmentation.

*12 months is listed by WPATH v7, whereas, 2 years is listed by, Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline (2009).

Permanent Hair Removal

Surgical treatment for Gender Dysphoria is covered when the Eligibility Qualifications for Surgery are met:

4. Hair Removal: Hair removal related to genital reconstruction (e.g. electrolysis or laser) when part of a complete care plan and ordered by a physician.

Facial Reconstruction

Surgical treatment for Gender Dysphoria is covered when the Eligibility Qualifications for Surgery are met:

2. Surgery to change specified secondary sex characteristics, specifically:

Thyroid chondroplasty (removal or reduction of the Adam’s Apple); and

4. Hair Removal: Hair removal related to genital reconstruction (e.g. electrolysis or laser) when part of a complete care plan and ordered by a physician.

Youth Services

Note: WPATH guidelines address age of majority in a given country. For the purposes of this guideline, the age of majority is age 18. However, this refers to chronological age and not biological age. Where approval or denial of benefits is based solely on the age of the individual a case-by-case medical director review is necessary.