Policy: Transgender Services
Last Update: 2020-08
Issued in: California

This policy applies to Medicaid

Body Contouring:

Nationally recognized medical experts in the field of transgender health care have identified the following core services in treating gender dysphoria:

• Mental and behavioral health services
• Hormone therapy
• A variety of surgical procedures that bring primary and secondary gender characteristics into conformity with the individual’s identified gender

Medically necessary covered services are those services that “are reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis and treatment of disease, illness or injury” (California Code of Regulations [CCR], Title 22, Section 51303). Medical necessity is assessed and services shall be recommended by treating licensed mental health professionals and physicians and surgeons experienced in treating patients with gender dysphoria.

In the case of transgender services, “normal appearance” is determined by referencing the gender with which the recipient identifies. Reconstructive surgery to create a normal appearance for transgender recipients is determined to be medically necessary for the treatment of gender dysphoria on a case-by-case basis.

A service or the frequency of services available to a transgender recipient cannot be categorically limited. All medically necessary services must be provided timely. Limitations and exclusions, medical necessity determinations and/or appropriate utilization management criteria that are non-discriminatory may be applied.

Breast Reconstruction:

Nationally recognized medical experts in the field of transgender health care have identified the following core services in treating gender dysphoria:

• Mental and behavioral health services
• Hormone therapy
• A variety of surgical procedures that bring primary and secondary gender characteristics into conformity with the individual’s identified gender

Medically necessary covered services are those services that “are reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis and treatment of disease, illness or injury” (California Code of Regulations [CCR], Title 22, Section 51303). Medical necessity is assessed and services shall be recommended by treating licensed mental health professionals and physicians and surgeons experienced in treating patients with gender dysphoria.

In the case of transgender services, “normal appearance” is determined by referencing the gender with which the recipient identifies. Reconstructive surgery to create a normal appearance for transgender recipients is determined to be medically necessary for the treatment of gender dysphoria on a case-by-case basis.

A service or the frequency of services available to a transgender recipient cannot be categorically limited. All medically necessary services must be provided timely. Limitations and exclusions, medical necessity determinations and/or appropriate utilization management criteria that are non-discriminatory may be applied.

Facial Reconstruction:

Nationally recognized medical experts in the field of transgender health care have identified the following core services in treating gender dysphoria:

• Mental and behavioral health services
• Hormone therapy
• A variety of surgical procedures that bring primary and secondary gender characteristics into conformity with the individual’s identified gender

Medically necessary covered services are those services that “are reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis and treatment of disease, illness or injury” (California Code of Regulations [CCR], Title 22, Section 51303). Medical necessity is assessed and services shall be recommended by treating licensed mental health professionals and physicians and surgeons experienced in treating patients with gender dysphoria.

In the case of transgender services, “normal appearance” is determined by referencing the gender with which the recipient identifies. Reconstructive surgery to create a normal appearance for transgender recipients is determined to be medically necessary for the treatment of gender dysphoria on a case-by-case basis.

A service or the frequency of services available to a transgender recipient cannot be categorically limited. All medically necessary services must be provided timely. Limitations and exclusions, medical necessity determinations and/or appropriate utilization management criteria that are non-discriminatory may be applied.

Permanent Hair Removal:

Nationally recognized medical experts in the field of transgender health care have identified the following core services in treating gender dysphoria:

• Mental and behavioral health services
• Hormone therapy
• A variety of surgical procedures that bring primary and secondary gender characteristics into conformity with the individual’s identified gender

Medically necessary covered services are those services that “are reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis and treatment of disease, illness or injury” (California Code of Regulations [CCR], Title 22, Section 51303). Medical necessity is assessed and services shall be recommended by treating licensed mental health professionals and physicians and surgeons experienced in treating patients with gender dysphoria.

In the case of transgender services, “normal appearance” is determined by referencing the gender with which the recipient identifies. Reconstructive surgery to create a normal appearance for transgender recipients is determined to be medically necessary for the treatment of gender dysphoria on a case-by-case basis.

A service or the frequency of services available to a transgender recipient cannot be categorically limited. All medically necessary services must be provided timely. Limitations and exclusions, medical necessity determinations and/or appropriate utilization management criteria that are non-discriminatory may be applied.

Voice Therapy and Surgery:

Nationally recognized medical experts in the field of transgender health care have identified the following core services in treating gender dysphoria:

• Mental and behavioral health services
• Hormone therapy
• A variety of surgical procedures that bring primary and secondary gender characteristics into conformity with the individual’s identified gender

Medically necessary covered services are those services that “are reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis and treatment of disease, illness or injury” (California Code of Regulations [CCR], Title 22, Section 51303). Medical necessity is assessed and services shall be recommended by treating licensed mental health professionals and physicians and surgeons experienced in treating patients with gender dysphoria.

In the case of transgender services, “normal appearance” is determined by referencing the gender with which the recipient identifies. Reconstructive surgery to create a normal appearance for transgender recipients is determined to be medically necessary for the treatment of gender dysphoria on a case-by-case basis.

A service or the frequency of services available to a transgender recipient cannot be categorically limited. All medically necessary services must be provided timely. Limitations and exclusions, medical necessity determinations and/or appropriate utilization management criteria that are non-discriminatory may be applied.