Policy: Gender Dysphoria
Policy Number: CCP.1358
Last Update: 2019-02-05
Issued in: Louisiana

This policy applies to Medicaid

Breast Reconstruction:

Breast/Chest Surgery. Breast augmentation and mastectomy for female to male (transmen) and creation of male chest for male to female (transwomen) members are considered medically necessary when the following criteria are met:

1. Persistent gender dysphoria is well documented.
2. Member has the capacity to make informed decisions and consent to treatment.
3. Member is of majority (adults only).
4. Any significant medical or mental health concerns are controlled.
5. Member has had at least 12 months of feminizing hormone therapy (recommended for breast augmentation).
6. One letter of referral is submitted.

Youth Services:

The member is an adult age 18 or older, or documented as an emancipated adolescent, or has documentation of appropriate consent from parent or guardian.

Various hormones can be given to members not of majority age undergoing gender transformation.