Policy: Clinical Guidelines and Coverage Criteria for the Treatment of Gender Dysphoria
Last Update: 2020-08-29
Issued in: New York

This policy applies to Medicaid

Breast Reconstruction:

Amida Care performs administrative prior authorizations only for the following procedures included in 18 NYCRR 505.2(l), paragraph 4: ... breast augmentation.

The member has completed a minimum of 24 months of hormone therapy, during which time breast growth has been negligible; or hormone therapy is medically contraindicated; or the patient is otherwise unable to take hormones

Facial Reconstruction:

Requires supporting documentation that indicates specific type of FFS procedures requested.

Permanent Hair Removal:

Requires clinical documentation establishing service is medically necessary and not cosmetic.

Voice Therapy and Surgery:

Requires supporting documentation that indicates procedures requested are medically necessary.

Youth Services:

Hormone therapy, whether or not in preparation for gender reassignment surgery, shall be covered as follows:

• Testosterone requires prior authorization for members with gender dysphoria diagnosis.
• The following do not require a prior authorization:
  • treatment with gonadotropin-releasing hormone agents (pubertal suppressants), based upon a determination by a qualified medical professional that a member is eligible and ready for such treatment, i.e., that the member:
    • meets the criteria for a diagnosis of gender dysphoria
    • has experienced puberty to at least Tanner stage 2, and pubertal changes have resulted in an increase in gender dysphoria does not suffer from psychiatric comorbidity that interferes with the diagnostic work-up or treatment; has adequate psychological and social support during treatment demonstrates knowledge and understanding of the expected outcomes of treatment with pubertal suppressants and cross-sex hormones, as well as the medical and social risks and benefits of sex reassignment treatment with cross-sex hormones for members who are sixteen years of age and older, based upon a determination of medical necessity made by a qualified medical professional; members who are under sixteen years of age who meet treatment criteria shall be covered in specific cases if medical necessity is demonstrated and prior approval is received. [18 NYCRR 505.2_Section 505.2 - Physicians' services]

For members under eighteen (18) years of age coverage be made in specific cases if medical necessity is demonstrated and prior approval is received.

Notes:

• Amida Care Transgender Health
• A Guide to Accessing Gender Affirming Services: English/Spanish
• Gender Affirming Surgery Consult Questions: English/Spanish
• Letters of Support for Gender Dysphoria Treatment – NYS Medicaid Guidance:English/Spanish
• Gender Identity Support Team (GIST) FAQs: English/Spanish
• Clinical Guidelines and Coverage Criteria for the Treatment of Gender Dysphoria: English/Spanish
• Transgender Drug Formulary: English/Spanish
• Referral Guide: English/ Spanish
• Provider Listing – Gender Affirming Surgery and Services: English/ Spanish