Policy: Gender Dysphoria (West Virginia Marketplace)
Policy Number: MM-0745
Last Update: 2019-09-01
Issued in: West Virginia

Breast Reconstruction:

SERVICES REQUIRING MEDICAL NECESSITY REVIEW

1. All members requesting ANY of the sexual reassignment surgeries (see list below).
   1. MtF
      1. 01. Breast reconstruction

Permanent Hair Removal:

Hair removal may be simultaneously approved with genital surgery based on medical necessity when skin flap area contains hair needing to be removed

SERVICES REQUIRING MEDICAL NECESSITY REVIEW

Hair removal

1. All members requesting ANY of the hair removal procedures for anticipated skin flap areas to create the new structures (does not include the perineum)
   1. Creation of a neovagina in MtF (does not include vulvoplasty alone)
   2. Creation of a neophallus in FtM