Policy: Gender Reassignment Surgery
Policy Number: 7.01.557
Last Update: 2021-04
Issued in: Washington

Breast Reconstruction:

One recommendation letter within the last six months from a licensed mental health professional

The required minimum content of the recommendation letter:

• Document a comprehensive evaluation
  • Confirmation of the diagnosis of gender dysphoria or gender identity disorder
  • An assessment of the member’s capacity to make a fully informed decision about proceeding with the surgery
  • Identification of any co-morbid psychiatric disorders or other mental health concerns with documentation that those are not influencing the individual’s decision regarding surgery, are not contraindications to surgery, and are not likely to cause a negative psychiatric outcome after the surgery
  • Verification that the member’s decision is current, is well thought out, is not impulsive, and is not due to any other potentially treatable mental disorder

Documentation from the surgeon that there are no medical contraindications to surgery

Augmentation mammaplasty for male to female patients

All of the above, plus, one of the following:

• Documentation of failure of breast growth stimulation by estrogen, specifically, progression to no more than a young adolescent stage of development OR
• Documentation of emergence of serious or intolerable adverse effects during estrogen administration OR
• Documentation of medical contraindication to use of estrogen OR
• Documentation of a risk-benefit analysis determining that surgery is preferable to estrogen therapy

Permanent Hair Removal:

Hair removal procedures (including electrolysis) may be considered medically necessary to treat tissue donor sites prior to phalloplasty or vaginoplasty.