Policy: Gender Affirmation Surgery
Policy Number: S-184-011
Last Update: 2021-01-01
Issued in: Delaware

Breast Reconstruction:

Gender affirmation surgery may be considered medically necessary when ALL of the following are met:

• The individual is greater than or equal to 18 years of age; and
• The individual has the capacity to make a fully informed decision and to consent for treatment; and
• The individual has been diagnosed with the gender dysphoria, including ALL of the following:
• The desire to live and be accepted as a member of another gender, usually accompanied by the wish to make their body as congruent as possible with the preferred sex through surgery and hormone treatment; and
• The individual's transgender identity has been present persistently for at least six (6) months; and
• The dysphoria is not a symptom of another mental disorder; and
• The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The individual is under the care of physicians and/or mental health providers who are able to document ALL of the following conditions:
• For chest surgery (mastectomy and chest reconstruction)
  • Initiation of hormonal therapy (unless medically contraindicated or individual is unable or unwilling to take hormones); and
  • One referral from a qualified mental health professional with written documentation submitted to the physician performing the breast surgery;

When ALL of the above criteria are met, the following breast/genital surgeries may be considered medically necessary:

Feminization procedures:

Breast augmentation

Note: Although not a requirement, it is recommended that individuals undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.