Policy: Prioritized List of Health Services - Gender Dysphoria/Transsexualism
Policy Number: Line 312
Last Update: 2020-11-09
Issued in: Oregon

This policy applies to Medicaid

Breast Reconstruction:

Mammoplasty (CPT 19316, 19324-19325, 19340, 19342, 19350) is only included on this line when 12 continuous months of hormonal (estrogen) therapy has failed to result in breast tissue growth of Tanner Stage 5 on the puberty scale OR there is any contraindication to, intolerance of or patient refusal of hormonal therapy.

Sex reassignment surgery is included for patients who are sufficiently physically fit and meet eligibility criteria. To qualify for surgery, the patient must:

A) have persistent, well documented gender dysphoria

B) for genital surgeries, have completed twelve months of continuous hormone therapy as appropriate to the member’s gender goals unless hormones are not clinically indicated for the individual

C) have completed twelve months of living in a gender role that is congruent with their gender identity unless a medical and a mental health professional both determine that this requirement is not safe for the patient

D) have the capacity to make a fully informed decision and to give consent for treatment

E) have any significant medical or mental health concerns reasonably well controlled

F) for breast/chest surgeries, have one referral from a mental health professional provided in accordance with version 7 of the WPATH Standards of Care.

Facial Reconstruction:

Individuals have received coverage for facial gender confirmation surgery under the Oregon Health Plan.

Permanent Hair Removal:

Electrolysis (CPT 17380) and laser hair removal (CPT 17110,17111) are only included on this line as part of pre-surgical preparation for chest or genital surgical procedures also included on this line. These procedures are not included on this line for facial or other cosmetic procedures or as pre-surgical preparation for a procedure not included on this line.

Youth Services:

Hormone treatment with GnRH analogues for delaying the onset of puberty and/or continued pubertal development is included on this line for gender questioning children and adolescents. This therapy should be initiated at the first physical changes of puberty, confirmed by pubertal levels of estradiol or testosterone, but no earlier than Tanner stages 2-3. Prior to initiation of puberty suppression therapy, adolescents must fulfill eligibility and readiness criteria and must have a comprehensive mental health evaluation. Ongoing psychological care is strongly encouraged for continued puberty suppression therapy.

Cross-sex hormone therapy is included on this line for treatment of adolescents and adults with gender dysphoria who meet appropriate eligibility and readiness criteria. To qualify for cross-sex hormone therapy, the patient must:

A) have persistent, well-documented gender dysphoria

B) have the capacity to make a fully informed decision and to give consent for treatment

C) have any significant medical or mental health concerns reasonably well controlled

D) have a comprehensive mental health evaluation provided in accordance with Version 7 of the World Professional Association for Transgender Health (WPATH) Standards of Care (www.wpath.org).