Policy: Gender Identity Services
Policy Number: MM.06.026
Last Update: 2021-03-08
Issued in: Hawaii

Fertility Preservation:

Fertility counseling is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. Fertility counseling is provided by a qualified health care professional;
2. The service is provided prior to removal of testes or ovaries; and
3. The counselor documents that the patient has been advised about contraceptive use, effects of transition on fertility, and options for fertility preservation and reproduction.

Permanent Hair Removal:

Removal of hair (both electrolysis and laser) on a skin graft prior to use in gender confirmation surgery is covered.

Precertification is not required for removal of hair (both electrolysis and laser) on a skin graft prior to use in gender confirmation surgery is covered.Sessions are limited to a total of 5 visits per member.

Youth Services:

Subcutaneous mastectomy, creation of a male chest for transmasculine individuals; including nipple reconstruction (if appropriate) is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. The patient is at least 16 years of age; if the candidate is less than 16 years of age, then treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet this criterion.
2. The patient has been diagnosed with persistent, well-documented gender dysphoria as defined by the current DSM criteria (see Appendix B) and gender identity disorder as defined by the current ICD criteria by a qualified health professional (see Appendix A);
3. Clinical records document that the patient has made a fully informed decision and consents to treatment or (if under age 18) assents to treatment and a parent/guardian consents to treatment;
4. The patient’s comorbid medical and mental health conditions (if present) are reasonably well-controlled; and
5. The patient has obtained a referral letter from a qualified mental health professional (see Appendix A).

Puberty suppression therapy is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. The patient has been diagnosed with persistent, well-documented gender dysphoria as defined by the current Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria (see Appendix B) and gender identity disorder as defined by the current International Classification of Diseases (ICD) criteria by a qualified health professional (see Appendix A);
2. The patient has exhibited the first physical changes of puberty, indicated by a minimum Tanner stage of 2
3. Clinical records document that the patient assents to treatment and the parent/guardian has made a fully informed decision and consents to treatment;
4. The patient’s comorbid medical and mental health conditions (if present) are reasonably well-controlled; and
5. Puberty suppression therapy will be administered in a safe, appropriate, medically supervised manner.

Continuous hormone replacement therapy is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. The patient is at least 16 years of age; if the candidate is less than 16 years of age, then treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet this criterion.
2. The patient has been diagnosed with persistent, well-documented gender dysphoria as defined by the current DSM criteria (see Appendix B) and gender identity disorder as defined by the current ICD criteria by a qualified health professional (see Appendix A);
3. Clinical records document that the patient has made a fully informed decision and (if at least age 18) consents to treatment or (if under age 18) assents to treatment and a parent/guardian consents to treatment;
4. The patient’s comorbid medical and mental health conditions (if present) are reasonably well-controlled; and
5. Continuous hormone replacement therapy will be administered in a safe, appropriate, medically supervised manner.