Policy: Gender Dysphoria and Gender Confirmation Treatment
Policy Number: MP307
Next Update: 2019-09-01
Issued in: Pennsylvania

This policy applies to Medicaid

This policy applies to Medicare

Breast Reconstruction:

Gender confirming services may be considered medically necessary when supporting documentation is provided by the clinicians (physicians and mental health professionals) confirms ALL of the following:

• The member is 18 years of age or older *; and
• The member has been diagnosed with Gender Dysphoria; and
• The member has expressed a desire to transition his/her body to the preferred gender through surgery and hormone replacement therapy** (if not otherwise contraindicated); and
• The member has completed a psychological assessment (psychotherapy may be recommended, but is not required) by a behavioral health professional with a doctoral degree (Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D) who is capable of adequately evaluating if the candidate has any co-morbid psychiatric conditions; and;
• A medical evaluation has been completed by a MD/DO; and
• The gender confirming surgery has been recommended by:
  • “One referral from a qualified mental health professional is needed for breast/chest surgery (e.g., mastectomy, chest reconstruction, or augmentation mammoplasty)”

Facial Reconstruction:

Facial implants, injections, or bone reduction (may be considered on a per-case basis with appropriate clinical documentation)

Voice Therapy and Surgery:

Voice modification surgery

Voice/speech therapy

Youth Services:

Peri-pubertal – gonadotropin-releasing hormone (GnRH) analogs to achieve suppression of pubertal hormones may be considered once the member reaches Tanner Stage* 2

*The Tanner Scale is measurement of physical development in children, adolescents and adults.

http://www.childgrowthfoundation.org/CMS/FILES/Puberty_and_the_Tanner_Stages.pdf

• Between 14 – 16 yrs of age –pubertal development of the desired opposite sex can be using a gradually increasing dose schedule of cross-gender hormone.

• Adolescents should be treated with GnRH analogues, progestins (e.g., medroxyprogesterone) or other medications that block and/or neutralize testosterone, estrogens and progesterone secretion.

Surgical Treatment

Per WPATH guidelines, “Chest surgery in FtM patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression.”