Policy: Gender Dysphoria Treatment Excluding California (Oklahoma, Oregon, Texas, Washington)
Policy Number: MMG153.G
Last Update: 2020-11-01
Issued in: Oklahoma, Oregon, Texas, Washington

Body Contouring:

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The documentation requirements outline below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.

Breast Reconstruction:

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The documentation requirements outline below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.

Permanent Hair Removal:

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