Skip to main content

Keyboard Shortcuts

Key Pair Function
Alt S Search Box
Alt T Top of Page
Alt H Home Page
Alt Index Button
Alt Next Button
Alt Prev Button
A4TE Logo

A4TE's Trans Health Project

Working for Transgender Equal Rights
Menu
  • Trans Health Insurance Tutorial
    • Choosing a Plan
    • Understanding Your Plan
    • Applying for Coverage
    • Understanding a Denial
    • Appealing a Denial
  • About Us
    • About A4TE's Trans Health Project
    • Privacy Policy
  • Contact Us
    • Contact A4TE
    • Contact A4TE's Trans Health Project
  • Resources
    • Legal Analysis
    • Medical Necessity Literature Reviews
    • Reporting Medical Provider Discrimination
    • Training Materials for Advocates
    • Provider Medical Necessity Letter Checklists
    • Health Insurance Medical Policies
    • Medical Organization Statements
    • State Health Insurance Laws and Guidance
    • Medicaid Regulations and Guidance
    • Gender Centers
    • Finding Trans Health Care Providers
    • State Employee Health Plans
    • Financial Aid for Transgender Surgeries
    • Gender Affirming Surgery Appeal Template
  • Tutorial del Seguro de Salud Trans
    • Cómo elegir un plan
    • Cómo entender su plan
    • Cómo solicitar cobertura
    • Cómo entender una denegación
    • Cómo apelar una denegación
Previous Page
Prev
Home
Home
Up
Up
Next Page
Next
  •  Home
  • Resources
  • Health Insurance Medical Policies
  • Current: Inland Empire Health Plan (IEHP) (Medi-Cal) - Gender Dysphoria

Prev Index Gender Dysphoria/Reassignment [103 of 162] Next

Inland Empire Health Plan (IEHP) (Medi-Cal)

Gender Dysphoria


Policy: Gender Dysphoria
Policy Number: UM_SUR 04
Last Update: 2019-03-28
Issued in: California

Breast Reconstruction:

Chest and Genital Gender-Affirming Surgical Consultation:

  1. The individual must have a diagnosis of persistent gender dysphoria.
  2. The individual must be able to provide informed consent. Feminizing/masculinizing gender-affirming surgery will lead to irreversible physical changes and/or potential adverse effects, and the individual must have the capacity to make a fully informed decision to consent to treatment.
  3. A Medical Evaluation Form is to be completed (see Attachment B). Alternatively, the Provider may submit the same content in the clinical documentation.
  4. The Provider or Therapist Documentation Form for Evaluation for Transgender Surgery is to be completed (see Attachment C). Alternatively, a letter from the Provider addressing the same content as Attachment C is acceptable.

a. One form/letter (for chest surgeries) from an individual’s treating Primary Care Provider or mental health professional endorsing the request in writing is required for the following chest surgeries:

i. (M to F) Augmentation mammoplasty;

Facial Reconstruction:

Facial Reconstructive Surgical Consultation:

a. The individual must have a diagnosis of persistent gender dysphoria.

b. The individual must be 18 years of age or older.

c. The individual must be able to provide informed consent;

i. Feminizing/Masculinizing gender-affirming surgery will lead to irreversible physical changes and/or potential adverse effects, and the individual must have the capacity to make a fully informed decision to consent to treatment.

ii. The treating surgeon must show that the individual has received appropriate education prior to the proposed procedure.

d. Evidence of 12 continuous months of hormone therapy, unless medical contraindication to hormone therapy documented.

e. Member has lived as the preferred gender for 12 continuous months.

f. A Medical Evaluation Form is to be completed (see Attachment B).

Alternatively, the Provider may submit the same content in the clinical documentation.

g. The Provider or Therapist Documentation Form for Evaluation for Transgender Surgery is to be completed (see Attachment C). Alternatively, a letter from the Provider addressing the same content as Attachment C is acceptable.

i. The form/letter must evaluate facial feature(s) that cause persistent gender dysphoria, clarify goals and expectations, and assess self-acceptance, AND

ii. Address how the presence of stated feature(s) impair function in relation to activities of daily living, AND

iii. Address how reconstruction of said features will improve quality of life and daily function.

2. Facial Reconstructive Surgery requests:

a. All components of facial reconstructive consultation requests have been completed;

b. Clear documentation of proposed facial reconstructive procedures with evidence, to include photos, justifying medical necessity and reconstructive purpose of requested surgical procedure.

Permanent Hair Removal:

Please refer to UM Subcommittee Approved Guideline Hair Removal for hair reduction consultation and procedure authorization criteria.

Back to top

Updated on Nov 30, 2020

Donate Now
Facebook Button Instagram Button
 Keyboard Shortcuts
 Privacy Policy
 A4TE Website

Copyright © 2024 Advocates For Trans Equality, Inc.  |  Tel: (202) 642-4542