Policy: Gender Affirmation Treatment & Procedures
Policy Number: CMS07.05
Last Update: 2021-11-01
Issued in: Maryland

Breast Reconstruction:

Breast/Chest Surgery: When benefits are provided under the member’s contract, JHHC will authorize gender reassignment breast/chest surgery when ALL of the following criteria are met:

a. One letter of referral (letter of medical necessity) from a licensed mental health professional, AND

b. Persistent, well-documented gender dysphoria, AND

c. Capacity to make fully informed decisions and consent for treatment, AND;

d. The member has reached the legal age of medical consent, AND

e. If significant medical or mental health issues present, they must be sufficiently (reasonably well) controlled

f. Female-to-male breast/chest surgery does not require hormone therapy as a pre-requisite for the covered procedures noted in section E. 1. a. below.

g. Male-to-female breast/chest surgery is covered when ALL of the following have been met for the covered procedure noted in section E. 1. c. below:

i. Breast size measures less than Tanner stage 5 after undergoing 12 months of hormone therapy, AND

ii. Breast size continues to cause clinically significant distress in social, occupational, or other areas of functioning as documented by a qualified mental health provider as identified in section

Youth Services:

Hormones under 18: For individuals under the age of 18, screening for the presence of the diagnosis of Gender Dysphoria and for medical and mental health issues must be completed by two qualified health professionals, one of whom must be a physician.