University Health Alliance

Policy Number
MPP-0125-171201
Policy Issued In
Hawaii
Last Update
Breast Reconstruction

The following services are considered cosmetic and do not meet criteria for medical necessity:

Coverage exceptions can be requested for review on an individual basis. ... breast enlargement procedures such as augmentation mammoplasty and implants

Facial Reconstruction

The following services are considered cosmetic and do not meet criteria for medical necessity:

Coverage exceptions can be requested for review on an individual basis.

1. Blepharoplasty, body contouring (liposuction of the waist), breast enlargement procedures such as augmentation mammoplasty and implants, face-lifting, facial bone reduction, feminization of torso, hair removal, lip enhancement, reduction thyroid chondroplasty, rhinoplasty, skin resurfacing (dermabrasion, chemical peel), and voice modification surgery (laryngoplasty, cricothyroid approximation or shortening of the vocal cords), which have been used in feminization, are considered cosmetic.

2. Chin implants, lip reduction, masculinization of torso, and nose implants, which have been used to assist masculinization, are considered cosmetic.

Fertility Preservation

Fertility counseling is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

  1. Fertility counseling is provided by a qualified health care professional;
  2. The service is provided prior to removal of testes or ovaries; and
  3. The counselor documents that the patient has been advised about contraceptive use, effects of transition on fertility, and options for fertility preservation and reproduction.
Youth Services

Puberty suppression therapy is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

  1. The patient has been diagnosed with persistent, well-documented gender dysphoria as defined by the current Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria (see Appendix B) and gender identity disorder as defined by the current International Classification of Diseases (ICD) criteria by a qualified mental health professional (see Appendix A);
  2. The patient has exhibited the first physical changes of puberty, indicated by a minimum Tanner stage of 2 or 3;
  3. The patient has completed at least three months of successful continuous full time real-life experience in their gender identity across a wide span of life experiences and events (e.g., holidays, vacations, season-specific school and/or work experience, family events);
  4. Clinical records document that the patient assents to treatment and the parent/guardian has made a fully informed decision and consents to treatment;
  5. The patient’s comorbid medical and mental health conditions (if present) are reasonably well-controlled; and
  6. Puberty suppression therapy will be administered in a safe, appropriate, medically supervised manner.

Continuous hormone replacement therapy is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. The patient is at least 16 years of age;