- One comprehensive evaluation and recommendation within the last six months from a licensed mental health professional (see Guidelines below), AND
- Diagnosis of gender dysphoria (formerly gender identity disorder) confirmed by the evaluating mental health professional, AND
- 18 years of age or older, AND
- No medical contraindications to surgery
In addition, for augmentation mammaplasty for male to female patients, one of the following must be met:
- failure of breast growth stimulation by estrogen (progression only to a young adolescent stage of development), OR
- emergence of serious or intolerable adverse effects during estrogen administration, OR
- medical contraindication to use of estrogen, OR
- risk-benefit analysis determined that surgery is preferable to estrogen therapy
Note: The criteria above apply for initial male to female augmentation mammaplasty, Additional breast augmentation after an initial augmentation mammaplasty is considered to be a feminization or cosmetic procedure, and therefore, member contract stipulations for feminization or cosmetic procedures (either contract exclusion or coverage criteria, whichever is applicable for the member’s health plan) apply.
Correction or repair of complications:
Surgery to correct or repair complications of gender altering genital or breast/chest surgery may be considered medically necessary for complications that cause significant discomfort or significant functional impairment. Surgery to revise, or to reverse and redo, specific gender altering genital or breast/chest procedures, may be considered medically necessary when correction or repair of complications requires revision or undoing of the original genital or breast/chest procedure. (Example: Baker IV contracture after breast augmentation necessitates removal of the implants, and replacement with smaller implants.)
Hair removal procedures (including electrolysis) may be considered medically necessary to treat tissue donor sites prior to phalloplasty or vaginoplasty.