Policy: Gender Reassignment Surgery
Last Update: 2021-02-22
Issued in: Minnesota

Breast Reconstruction:

1. All of the following criteria must be met prior to mastectomy for female to male members or breast augmentation for male to female members:
   1. The member must:
      1. Have persistent, well documented gender dysphoria; and
      2. Have the capacity to make a fully informed decision and to consent for treatment; and
      3. Have one referral from a qualified mental health professional that addresses all of the following:
         1. The member’s general identifying characteristics; and
         2. Results of the member’s psychosocial assessment, including any diagnoses; and
         3. The duration of the mental health professional’s relationship with the member including the type of evaluation and therapy or counseling to date; and
         4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the member’s request for surgery; and
         5. A statement that informed consent has been obtained from the patient; and
         6. A statement that the mental health professional is available for coordination of care.
   2. If significant medical or mental health concerns are present, documentation must support that they are reasonably well controlled.

Please note: Hormone therapy is not a prerequisite to mastectomy or breast augmentation.

Youth Services:

No age requirement for surgery.