Policy: Transgender Surgery
Policy Number: UR 75
Last Update: 2021-02

Breast Reconstruction:

MtF members are eligible for Breast Augmentation if they meet all of the following criteria:

1. Single letter of referral from a qualified mental health professional; and
2. Persistent, well-documented gender dysphoria per DSM 5 Gender Dysphoria; and
3. Capacity to make a fully informed decision and to consent for treatment; and
4. Age 18 years or older (Note: age requirement will not be applied to augmentation in Male-to-Female patients if the surgeon, the primary care provider, and the qualified mental health professional unanimously document the medical necessity of earlier intervention); and
5. If significant medical or mental health concerns are present, they must be reasonably well controlled. The health plan may require a second opinion regarding the patient’s stability prior to surgery if in question; and
6. Twelve months of living in a gender role that is congruent with their gender identity (real life experience) and
7. Twelve months of continuous hormone therapy as appropriate to the member’s gender goals.

If the referring medical provider or mental health provider requests surgical intervention prior to the patient’s completion of 12 months of hormone therapy and/or living in desired gender, the surgeon, the primary care provider, and the qualified mental health professional must submit evidence of medical necessity and clear rationale for the proposed surgical intervention to be done early.

The three providers must submit written documentation to the plan that includes:

a. A comprehensive, coordinated treatment plan with evidence that all treatment plan criteria for surgery and treatment goals have been met; and

b. Clear rationale for the variation from either the 12-month period of hormone therapy and/or living for 12 months in desired gender; and

c. Patient understands the treatment plan, risks and benefits of surgery prior to completing the 12- month period.

The plan will determine authorization and consent to care based on medical necessity from the documentation outlined in 1-7 above. The criteria above apply for only initial male to female augmentation mammaplasty, any additional breast augmentation after an initial mammaplasty is considered a cosmetic procedure, and therefore, a contract exclusion.

Facial Reconstruction:

Male-to-Female (MtF): Tracheal Shave and facial hair removal as well as surgical area hair removal by electrolysis or laser are covered when referred by a Gender Pathways provider.

Permanent Hair Removal:

Male-to-Female (MtF): Tracheal Shave and facial hair removal as well as surgical area hair removal by electrolysis or laser are covered when referred by a Gender Pathways provider.

Youth Services:

For FtM members under the age of 18, chest surgery can be carried out on adolescents 16 years or older after ample time of living in the desired gender role and after one year of testosterone treatment. Adolescent FtM patients seeking chest surgery must also meet criteria 2-6 above and must have parental consent or be legally emancipated.

Notes:

Please go to page 86