Policy: Gender Transition Services
Policy Number: MP-033-MD-PA
Last Update: 2020-03-16
Issued in: Pennsylvania

This policy applies to Medicaid

Breast Reconstruction:

Gender transition surgery involving the masculinization of breast/chest surgery is considered medically necessary when all of the following criteria are met:

Persistent, well documented diagnosis of gender dysphoria, including the following:

1. The desire to live and be accepted as a person whose gender is different than assigned at birth, typically accompanied by the desire to make the physical body as congruent as possible with the identified gender through surgery and hormone treatment; AND
2. The desire for alternate gender identity has been present for at least 6 months; AND
3. The gender dysphoria causes clinical distress or social impairment in social, occupation, or other important areas of functioning; AND Minimum of 18 years of age, or on a case-by-case basis, the minimum age of 18 years may be reconsidered for mastectomy surgeries if sufficient documentation is provided, all other criteria have been met, and the presence of breasts precludes the patient from successfully adopting a male or androgynous gender role; AND When significant medical or mental health issues are present, there must be attempts to achieve reasonable control. There should be an independent single referral from a qualified mental health professional.

The following gender confirmation surgeries are eligible services when all of the above criteria are met:

A. Transwomen (male to female): ... Augmentation mammoplasty

Voice Therapy and Surgery:

The following gender confirmation surgeries are eligible services when all of the above criteria are met:

A. Transwomen (male to female): ... Laryngoplasty

Youth Services:

Puberty-suppressing hormones in adolescents criteria

• The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed); AND
• Gender dysphoria emerged or worsened with the onset of puberty; AND
• Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment; AND
• The adolescent has been given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.
• Initiation of hormone therapy is recommended by a qualified health professional with written documentation; AND
• Laboratory testing to monitor the safety of continuous hormone therapy; AND
• Hormonal treatment can occur before the age of 18 after discontinuation of pituitary-blocking agents.