Policy: Gender Affirming Surgery
Policy Number: 0615
Last Update: 2021-01-12

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:

Mastectomy: members below the age of majority (less than 18 years of age), completion of one year of testosterone treatment;