Gender affirmation surgery involving feminizing breast/chest surgery is considered medically necessary and covered when all of the criteria below are met:
- A persistent, well-documented diagnosis of gender dysphoria (as outlined in the Definitions Section), including all of the following indications:
- The desire to live and be accepted as a person whose gender is different than that assigned at birth, typically accompanied by the desire to make the physical body as congruent as possible with the identified gender through surgery and hormone treatment; and
- The desire for alternate gender identity has been present for at least 6 months; and
- The gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning; and
- Minimum 18 years of age* (see Variations); and
- The mental capacity for fully-informed consent as outlined in the Definitions Section; and
- A minimum of 12 months of continuous hormonal therapy, as recommended, as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable to take hormones).
- If significant medical or mental health issues are present, they must be reasonably well-controlled.
- One referral from a qualified mental health professional (see Definitions Section) who has independently assessed the patient.
*Medicaid plans: For feminizing breast/chest surgery, patients younger than 18 years of age will be reviewed by a Medical Director.
Information Required for Review
In order to determine medical necessity for covered gender affirmation surgical procedures, adequate information must be furnished by the treating physician. Required documentation includes all of the following:
1. Letter of medical necessity including documentation of the following:
Date of birth
- Diagnosis of persistent well-documented gender dysphoria according to DSM-V criteria as defined above
- Capacity to provide fully-informed consent
2. Progress notes showing clear documentation of the experience in the gender role including the start date of living full time in the gender role. Notes must reflect the above listed appropriate number of months of living full time in a gender role that is congruent with their gender identity (if applicable).
3. Documentation of type(s) of hormonal therapy used, including dates of initiation and discontinuation (if applicable).
4. Documentation of breast size after 12 months of hormone therapy for MtF (if applicable).
5. Documentation that fully informed consent for the requested surgery was obtained.
6. Documentation (if applicable) of the presence and nature of any significant medical or mental health conditions, and documentation that they are reasonably well-controlled.
7. Documentation of one referral from qualified mental health professionals (see Definitions Section) who have independently assessed the patient.
Hair removal is only considered medically necessary for any skin used to build a urethra or vagina. This is considered part of the genital surgery and will not be paid separately unless:
- The surgeon documents why they are unable to oversee or perform the procedure themselves; and
- The identified electrolysis provider must be able to perform ‘true needle electrolysis’, is certified in electrology, be an active member of the American Electrology Association (AEA), and holds an active Cosmetology License in Pennsylvania; and
- The procedure will be for permanent hair removal on skin used to build a urethra or vagina only.
Chondroplasty, voice modification and voice lessons will be considered when medically necessary.
Minimum 18 years of age or on a case by case basis, the minimum age of 18 years may be reconsidered for mastectomy surgeries if sufficient documentation is provided, all other criteria have been met, and the presence of the breasts precludes the patient from successfully adopting a male or androgynous gender role.
Medicaid plans: For feminizing breast/chest surgery, patients younger than 18 years of age will be reviewed by a Medical Director.