Policy: Gender Affirming Surgery
Policy Number: 0615
Last Update: 2023-08-08

This policy applies to Medicaid

Breast Reconstruction:

Requirements for breast augmentation (implants/lipofilling):

Note: More than one breast augmentation is considered not medically necessary. This does not include the medically necessary replacement of breast implants (see CPB 0142 - Breast Implant Removal).

Youth Services:

• For Breast Removal: For members less than 18 years of age, completion of one year of testosterone treatment, unless hormone therapy is not desired or medically contraindicated
• For Breast Augmentation: Completion of six months of feminizing hormone therapy (12 months for adolescents less than 18 years of age) prior to breast augmentation surgery, unless hormone therapy is not desired or medically contraindicated)
• For Gonadectomy: Six months of continuous hormone therapy as appropriate to the member's gender goals (12 months for adolescents less than 18 years of age), unless hormone therapy is not desired or medically contraindicated.
• For Genital Reconstruction: Six months of continuous hormone therapy as appropriate to the member’s gender goals (12 months for adolescents less than 18 years of age), unless hormone therapy is not desired or medically contraindicated.