Policy: Gender Affirming Interventions for Gender Dysphoria
Policy Number: 153
Last Update: 2021-09-01
Next Update: 2022-09
Issued in: Utah

Breast Reconstruction:

Gender affirming surgical interventions for gender dysphoria may be considered medically necessary when both of the following criteria are met (A - B):

A. All of following general criteria are met (1 - 5):

1. Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); an
2. Clinical records document that the patient has the capacity to make fully informed decisions and consent for intervention, and that any other mental health condition, if present, is adequately controlled; and
3. At least 2 licensed mental health professionals have diagnosed gender dysphoria, and recommend surgical intervention (Note: only 1 mental health professional referral is required for mastectomy); and
4. Documentation of continuous hormonal therapy for at least 12 months, unless there is a documented contraindication to hormonal therapy (Notes: hormonal therapy is not required prior to mastectomy or breast augmentation; hormonal therapy for at least 6 months is required for endometrial ablation); and
5. At least 12 months of living in a role that is congruent with the patient’s

B. One or more of the following criteria are met: Clinical documentation is submitted expressly documenting that the intervention would improve otherwise documented significant gender dysphoria and the request is for one or more of the following procedures: Breast augmentation

Permanent Hair Removal:

One or more of the following criteria are met: Clinical documentation is submitted expressly documenting that the intervention would improve otherwise documented significant gender dysphoria and the request is for one or more of the following procedures: Hair removal

Youth Services:

Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); and