Policy: Transgender Services Benefits
Last Update: 2017-01-01
Issued in: Alabama

Breast Reconstruction:

A member must meet ALL the following criteria established under the World Professional Association for Transgender Health (WPATH) (7th version) in order to be eligible:

1. Diagnosis of Gender Identity Disorder (ICD-10 F64.0, F64.1 or F64.9); and
2. Age of majority (18 years of age or older); and
3. Have knowledge of the benefits and risks of surgery as demonstrated by and documented in an evaluationfrom a qualified mental health professional; and
4. Unless medically contraindicated, completion of twelve (12) months of continuous hormone therapy (EXCEPT for Mastectomy); and
5. Twelve continuous months of living in a congruent gender role with his/her gender identity (real life experience) prior to the gender reassignment services noted in the medical documentation (start/end dates included); and
6. If the member has significant medical or mental health issues present, they must be reasonably well controlled and noted in the medical documentation. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy prior to surgery and the effort(s) noted in the medical documentation; and
7. Two (2) referrals from qualified mental health professionals who have independently assessed the individual. 1 referral should be from a person who has only had an evaluative role with the individual. Both referring providers must submit letters of their evaluation. (At least 1 of the evaluating professionals must have a doctoral degree [PhD, MD, Ed.B, D. Sc, D.S.W. or Psy.D] and be capable of adequately evaluating co-morbid psychiatric conditions.)

BREAST DEVELOPMENT - female hormones for at least 12 months to achieve adequate breast development without surgery. Any further intervention by surgical means would be reviewed for medical necessity in accordance with medical policy #106 Reconstructive versus Cosmetic Surgery.