Policy: Gender Affirmation Surgeries
Policy Number: OCA 3.11 v.12
Last Update: 2021-07-01
Issued in: Massachusetts

This policy applies to Medicaid

Breast Reconstruction:

(1) Breast Augmentation (Feminizing Chest Reconstruction): This policy includes medical necessity criteria for the initial breast augmentation procedure as a component of gender affirmation surgery. Feminizing breast reconstruction for members with persistent, well-documented gender dysphoria includes augmentation mammoplasty with implantation of breast prostheses and/or the medically necessary surgical removal of breast implants with replacement of breast implants after implant explantation [sic].

Plan Medical Director review and approval are required when mastopexy and/or breast reconstruction are requested for the treatment of gender dysphoria (as a treatment alternative to augmentation mammoplasty) for feminizing breast reconstruction, as stated in the Limitations section of this policy. Review criteria in the Medical Policy Statement section of the Breast Reconstruction medical policy, policy number OCA 3.43, rather than the criteria included in this policy for Plan prior authorization guidelines for the surgical removal of breast implants and the replacement of breast implants after implant explantation [sic] (when the breast implants were initially inserted for breast reconstruction as a component of gender affirmation surgery).

Augmentation mammoplasty with implantation of breast prostheses (feminizing chest reconstruction) is considered medically necessary for members with persistent, well documented gender dysphoria when ALL of the following criteria are met for the initial breast augmentation for gender affirmation surgery and documented in the member’s medical record, as specified below in items (a) through (d):

(a) The treating surgeon has determined that the member has the capacity to make a fully-informed decision and has the capacity to consent for treatment (including parental or guardian consent, as applicable, if the member is younger than age 18 on the date of service or informed consent is obtained from an emancipated minor according to state requirements); AND

(b) If significant medical and/or mental health concerns are present, the treating surgeon has determined that the conditions are being optimally managed and are reasonably well controlled; AND

(c) The member has had 12 continuous months of physician-supervised hormone therapy (unless hormone therapy is medically contraindicated for the member), and the hormone therapy has not resulted in sufficient breast development as self-reported by the member to the treating provider; OR

(d) The treating surgeon has reviewed the written initial assessment by a qualified licensed mental health professional; the surgeon has confirmed that this assessment documents that the member has met DSM-5 criteria for persistent, well-documented gender dysphoria; and the treating surgeon is in agreement with the member’s diagnosis; AND ^ Note: The written assessment may be from the qualified licensed mental health professional performing the initial assessment/referral referenced in item A of this section (Referral/Initial Assessment by Qualified Licensed Mental Health Professional criteria).

Youth Services:

C. Member Age:

The member is age 18 or older* on the date of service

* Note: Plan Medical Director review is required for ANY gender affirmation surgery requested for a member less than age 18 on the date of service. Requests for surgical treatment will be reviewed based on the Plan’s Medically Necessary medical policy, policy number OCA 3.14, and the current version of the WPATH Standards of Care for Health and Transsexual, Transgender, and Gender-Nonconforming People. In addition, the Plan Medical Director will review the member’s clinical situation, including but not limited to the amount of time the adolescent member has been living in the desired gender role, treatment timeframe with hormone therapy, age of the member, and the requested intervention. Adolescent members may be eligible for interventions when adolescents and their parents (or guardian) make informed decisions about treatment, and the service is a covered benefit for the Plan member. Informed consent by a parent or guardian for treatment of an adolescent member may not apply if the adolescent member is emancipated at the time the service is rendered (as determined by state requirements).

Notes:

Gender affirmation surgeries are considered medically necessary as a treatment option for a member seeking treatment for gender dysphoria when the Plan’s applicable medical criteria are met, as specified in this Plan policy. Gender affirmation surgeries may include one (1) or more surgical procedures and are part of a complex treatment plan involving medical, surgical, and behavioral health interventions to achieve the desired outcomes for the individual. When gender affirmation surgeries are requested for a Plan member, prior authorization is required and applicable Plan criteria must be met for each type of surgical procedure. It will be determined during the Plan’s prior authorization process if each requested procedure is considered medically necessary for the specified indication, with medical necessary defined in the Definitions section of this policy and included in the Plan’s Medically Necessary medical policy, policy number OCA 3.14. The Plan will review all requests for breast augmentation or mastectomy to treat gender dysphoria for transfeminine, transmasculine, or non-binary members using the medical criteria included in this Plan medical policy (rather than other Plan medical policies related to the requested breast procedures). Breast reconstruction for transfeminine or non-binary members with persistent, well-documented gender dysphoria may include augmentation mammoplasty with implantation of breast prostheses and/or the medically necessary surgical removal of breast implants with replacement of breast implants after implant explantation. Review criteria in the Medical Policy Statement section of the Breast Reconstruction medical policy, policy number OCA 3.43, rather than the criteria included in this policy for Plan prior authorization guidelines for the surgical removal of breast implants and the replacement of breast implants after implant explantation when the breast implants were initially inserted for breast reconstruction as a component of gender affirmation surgeries.