Policy: Gender Dysphoria Treatment (Community Plan)
Policy Number: CS145.J
Last Update: 2021-11-01

This policy applies to Medicaid

Permanent Hair Removal:

Laser or electrolysis hair removal in advance of genital reconstruction prescribed by a physician for the treatment of gender dysphoria

Notes:

When the above criteria are met, the following surgical procedures to treat Gender Dysphoria are medically necessary

and covered as a proven benefit:

• Bilateral mastectomy or breast reduction*
• Clitoroplasty (creation of clitoris)
• Hysterectomy (removal of uterus)
• Labiaplasty (creation of labia)
• Laser or electrolysis hair removal in advance of genital reconstruction prescribed by a physician for the treatment of
• Gender Dysphoria
• Metoidioplasty (creation of penis, using clitoris)
• Orchiectomy (removal of testicles)
• Penectomy (removal of penis)
• Penile prosthesis
• Phalloplasty (creation of penis)
• Salpingooophorectomy (removal of fallopian tubes and ovaries)
• Scrotoplasty (creation of scrotum)
• Testicular prostheses
• Urethroplasty (reconstruction of female urethra)
• Urethroplasty (reconstruction of male urethra)
• Vaginectomy (removal of vagina)
• Vaginoplasty (creation of vagina)
• Vulvectomy (removal of vulva)

*When bilateral mastectomy or breast reduction is performed as a stand-alone procedure, without genital reconstruction procedures, completion of hormone therapy prior to the breast procedure is not required.