Policy: Gender Identity Services
Policy Number: MM.06.026
Last Update: 2019-08-23
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:

Pre-surgical electrolysis for the removal of hair on a skin graft prior to use in genital reassignment surgery is covered.

Voice Therapy and Surgery:

The following services are generally not considered to be medically necessary, but will be reviewed on an individual basis in accord with Section II of this Medical Policy:

1. Voice alteration surgery;

Youth Services:

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 mental 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. The patient has completed at least three months of successful continuous full time real-life experience in their gender identity across a wide span of life experiences and events (e.g., holidays, vacations, season-specific school and/or work experience, family events);
4. Clinical records document that the patient assents to treatment and the parent/guardian has made a fully informed decision and consent to treatment;
5. The patient’s comorbid medical and mental health conditions(if present) are reasonably well-controlled; and
6. Puberty suppression therapy will be administered in a safe, appropriate, medically supervised manner.

Continuous hormone replacement therapy is covered ... when ... 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.

Breast/chest surgery: subcutaneous mastectomy, creation of a male chest; including nipple reconstruction (if appropriate) is covered (subject to Limitations and Administrative Guidelines) when ... 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.