Policy Issued By: Aetna

Policy Title: Gender Affirming Surgery

Youth Services:

• For Breast Removal: For members less than 18 years of age, completion of one year of testosterone treatment, unless hormone therapy is not desired or medically contraindicated
• For Breast Augmentation: Completion of six months of feminizing hormone therapy (12 months for adolescents less than 18 years of age) prior to breast augmentation surgery, unless hormone therapy is not desired or medically contraindicated)
• For Gonadectomy: Six months of continuous hormone therapy as appropriate to the member's gender goals (12 months for adolescents less than 18 years of age), unless hormone therapy is not desired or medically contraindicated.
• For Genital Reconstruction: Six months of continuous hormone therapy as appropriate to the member’s gender goals (12 months for adolescents less than 18 years of age), unless hormone therapy is not desired or medically contraindicated. 

Policy Issued By: Aetna

Policy Title: Gonadotropin-Releasing Hormone Analogs and Antagonists

Youth Services:

Aetna considers Lupron Depot, Lupron Depot-PED, Leuprolide acetate (Eligard, Fensolvi), Goserelin (Zoladex), Vantas, Supprelin LA, and Triptorelin (Trelstar; Triptodur) medically necessary for the following indications: ... for pubertal suppression in preparation for gender reassignment in an adolescent member when all of the following criteria are met: 1. The member has a diagnosis of gender dysphoria; and 2. The member has reached Tanner stage 2 of puberty.

Policy Issued By: Aetna

Policy Title: Implantable Hormone Pellets

Youth Services:

If the member is less than 18 years of age, the requested medication will be prescribed by or in consultation with a provider specialized in the care of transgender youth (e.g., pediatric endocrinologist, family or internal medicine physician, obstetrician-gynecologist), that has collaborated care with a mental health care provider.

Policy Issued By: Aetna

Policy Title: Testosterone Cypionate Injection (Depo-Testosterone)

Youth Services:

For gender dysphoria, the medication must be prescribed by or in consultation with a provider specialized in the care of transgender youth (e.g., pediatric endocrinologist, family or internal medicine physician, obstetrician-gynecologist) that has collaborated care with a mental health provider for members less than 18 years of age.

1. In an adolescent member when all of the following criteria are met:
   
   1. The member has a diagnosis of gender dysphoria; and
   2. The member is able to make an informed decision to engage in hormone therapy; and
   3. The member has reached Tanner stage 2 of puberty or greater; and
   4. The member’s comorbid conditions are reasonably controlled; and
   5. The member has been educated on any contraindications and side effects to therapy; and
   6. The member has been informed of fertility preservation options.

Policy Issued By: AmeriHealth

Policy Title: Androgens

Youth Services:

For use as hormone therapy in children, adolescents, and adults with gender dysphoria when there is documentation of persistent, well-documented gender dysphoria diagnosed in accordance with criteria established in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)

Policy Issued By: Amida Care

Policy Title: Clinical Guidelines and Coverage Criteria for the Treatment of Gender Dysphoria

Youth Services:

Hormone therapy, whether or not in preparation for gender reassignment surgery, shall be covered as follows:

• Testosterone requires prior authorization for members with gender dysphoria diagnosis.
• The following do not require a prior authorization:
  • treatment with gonadotropin-releasing hormone agents (pubertal suppressants), based upon a determination by a qualified medical professional that a member is eligible and ready for such treatment, i.e., that the member:
    • meets the criteria for a diagnosis of gender dysphoria
    • has experienced puberty to at least Tanner stage 2, and pubertal changes have resulted in an increase in gender dysphoria does not suffer from psychiatric comorbidity that interferes with the diagnostic work-up or treatment; has adequate psychological and social support during treatment demonstrates knowledge and understanding of the expected outcomes of treatment with pubertal suppressants and cross-sex hormones, as well as the medical and social risks and benefits of sex reassignment treatment with cross-sex hormones for members who are sixteen years of age and older, based upon a determination of medical necessity made by a qualified medical professional; members who are under sixteen years of age who meet treatment criteria shall be covered in specific cases if medical necessity is demonstrated and prior approval is received. [18 NYCRR 505.2_Section 505.2 - Physicians' services]

For members under eighteen (18) years of age coverage be made in specific cases if medical necessity is demonstrated and prior approval is received.

Policy Issued By: Anthem

Policy Title: Gender Affirming Surgery

Youth Services:

A provider with experience treating adolescents with gender dysphoria may request further consideration of a gender affirming chest procedure case in an individual under 18 years old when they meet all other gender affirming chest procedure criteria above (including prior mental health evaluation) by contacting a Medical Director. (Further information is available in the Discussion/General Information section of this document titled ‘Gender Affirming Surgery in Individuals Under the Age of 18’).

Policy Issued By: Anthem Blue Cross (California)

Policy Title: Gender Affirming Surgery

Youth Services:

A provider with experience treating adolescents with gender dysphoria may request further consideration of a gender affirming chest procedure case in an individual under 18 years old when they meet all other gender affirming chest procedure criteria above (including prior mental health evaluation) by contacting a Medical Director. (Further information is available in the Discussion/General Information section of this document titled ‘Gender Affirming Surgery in Individuals Under the Age of 18’).

Policy Issued By: Blue Cross Blue Shield Federal Employee Program

Policy Title: GnRH Gender Dysphoria

Youth Services:

Off Label Use: GnRH analogues can be used in the treatment of Gender Dysphoria (GD) and should only be started once a diagnosis of GD or transsexualism has been made per the DSM V or ICD-10 criteria (1).

For Gender Dysphoria (GD):

MUST HAVE ALL of the following:

1. Prescribed by an endocrinologist or transgender specialist
2. Patient has met the DSM V criteria for GD

Policy Issued By: Blue Cross Blue Shield of New Mexico

Policy Title: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Youth Services:

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

• Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);
• Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or
• Chest surgery for FtM individuals.

Policy Issued By: Blue Cross Blue Shield of Oklahoma

Policy Title: Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

Youth Services:

A. Gender Reassignment Surgery and Related Services for Children and Adolescents:

The following services may be considered medically necessary for the treatment of gender dysphoria for children and adolescents:

• Hormone therapy (such as, puberty-suppressing hormones or masculinizing/feminizing hormones);
• Psychological services, including but not limited to psychotherapy, social therapy, and family counseling; and/or
• Chest surgery for female-to-male (FtM) individuals.

The individual being considered for surgery and related services must meet ALL the following criteria. The individual must have:

• Been diagnosed with persistent, well-documented gender dysphoria; and
• The required referrals prior to any surgery or related service(s):
  • Prior to feminizing or masculinizing hormonal therapy, one required referral from the individual’s qualified mental health professional (see NOTE 2) competent in the assessment and treatment of gender dysphoria; and/or
  • Prior to breast/chest surgery, e.g., mastectomy, chest reconstruction, or breast augmentation, one required referral from the individual’s qualified mental health professional (see NOTE 2) competent in the assessment and treatment of gender dysphoria.

NOTE 1: The 2012 World Professional Association for Transgender Health (WPATH) Version 7, Standards of Care (SOC) (6) state that adolescent individuals seeking irreversible interventions, such as genital surgery:

“Genital surgery should not be carried out until (i) patients reach the legal age of majority to give consent for medical procedures in a given country, and (ii) patients have lived continuously for at least 12 months in the gender role that is congruent with the gender identity. The age threshold should be seen as a minimum criterion and not an indication in and of itself for active intervention.”

Policy Issued By: Blue Cross Blue Shield of Rhode Island

Policy Title: Gender Affirming Care

Youth Services:

No age requirement for surgery.

Policy Issued By: Boston Medical Center HealthNet Plan / Well Sense

Policy Title: Gender Affirmation Surgeries

Youth Services:

C. Member Age:

The member is age 18 or older* on the date of service

* Note: Plan Medical Director review is required for ANY gender affirmation surgery requested for a member less than age 18 on the date of service. Requests for surgical treatment will be reviewed based on the Plan’s Medically Necessary medical policy, policy number OCA 3.14, and the current version of the WPATH Standards of Care for Health and Transsexual, Transgender, and Gender-Nonconforming People. In addition, the Plan Medical Director will review the member’s clinical situation, including but not limited to the amount of time the adolescent member has been living in the desired gender role, treatment timeframe with hormone therapy, age of the member, and the requested intervention. Adolescent members may be eligible for interventions when adolescents and their parents (or guardian) make informed decisions about treatment, and the service is a covered benefit for the Plan member. Informed consent by a parent or guardian for treatment of an adolescent member may not apply if the adolescent member is emancipated at the time the service is rendered (as determined by state requirements).

Policy Issued By: Boston Medical Center HealthNet Plan / Well Sense

Policy Title: GnRH Agents

Youth Services:

Preferred Agents:

Leuprolide, Lupron (leuprolide), Trelstar (triptorelin), Zoladex (goserelin) Documentation of the one of following:

1. Member is less than 18 years of age; AND

• A diagnosis of gender dysphoria/gender incongruent; AND
• Have experienced puberty to at least Tanner stage 2; AND
• Absence of psychiatric comorbidity that interferes with the diagnostic work-up or treatment; AND
• Have adequate psychological and social support during treatment; AND
• Demonstrate knowledge and understanding of the expected outcomes of GnRH analog treatment;
• OR
• Member age is 18 years or older; AND
• A diagnosis of gender dysphoria/gender incongruent; AND
• Capacity to make a well-informed decision and consent to treatment; AND
• Medical or mental issues if present are well-controlled; AND d. The regimen is a trans-feminine regimen (male to female); AND
• Failure to achieve physiologic hormone levels or an intolerance with use of oral estrogens and spironolactone

Policy Issued By: Cigna

Policy Title: Gender Dysphoria Treatment

Youth Services:

For initial mastectomy for an individual age 15 years to < age 17 years BOTH of the following:

• Parental/guardian consent, when applicable

• Two separate letters of support, each from an independent mental health provider experienced in adolescent mental health and the diagnosis and treatment of childhood gender dysphoria. Each mental health evaluation must confirm a diagnosis of gender dysphoria, confirm it is marked and sustained over time (e.g., two years), address any mental health comorbidities, and document the individual’s emotional and cognitive maturity necessary to provide informed consent.

Note: Initial mastectomy as part of gender reassignment surgery for an individual < than age 15 years is considered not medically necessary

Policy Issued By: ConnectiCare

Policy Title: Gender Reassignment Surgery (Medicare)

Youth Services:

Treatment with cross-sex hormones, including testosterone, cypionate, conjugated estrogen, and estradiol, for members greater than or equal to 16 years of age, when based upon a determination of medical necessity made by a qualified medical professional. (Members less than 18 years of age must meet Criteria # 1).

Note: Requests for coverage of cross-sex hormones for members less than 16 years of age will be reviewed on a case-by- case basis

Policy Issued By: Fallon Health

Policy Title: Gender Affirmation Services

Youth Services:

Puberty Suppression Hormone Therapy:

Adolescents with gender non-conformity or diagnosed gender dysphoria often begin hormone therapy at the onset of puberty. Given puberty suppression is reversible it allows an adolescent the ability to fully explore their gender non-conformity and make informed decisions regarding future treatment. Puberty Suppression hormone treatments are overseen by a Pediatric Endocrinologist and often a Mental Health professional.

In accordance with WPATH the below minimal criteria must be met

1. The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed);

2. Gender dysphoria emerged or worsened with the onset of puberty;

3. Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment;

4. The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.

Policy Issued By: Gateway Health

Policy Title: Gender Transition Services

Youth Services:

Puberty-suppressing hormones in adolescents criteria

• The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed); AND
• Gender dysphoria emerged or worsened with the onset of puberty; AND
• Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment; AND
• The adolescent has been given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.
• Initiation of hormone therapy is recommended by a qualified health professional with written documentation; AND
• Laboratory testing to monitor the safety of continuous hormone therapy; AND
• Hormonal treatment can occur before the age of 18 after discontinuation of pituitary-blocking agents.

Policy Issued By: Healthy Blue (Louisiana Medicaid)

Policy Title: Gender Reassignment Surgery

Youth Services:

A provider with experience treating adolescents with gender dysphoria may request further consideration of a bilateral mastectomy case in an individual under 18 years old when they meet all other bilateral mastectomy criteria above (including prior mental health evaluation) by contacting a Medical Director.  (Further information is available in the Discussion/General Information section of this document titled ‘Gender Reassignment Surgery in Individuals Under the Age of 18’).

Policy Issued By: Horizon Blue Cross Blue Shield of New Jersey

Policy Title: Gender Reassignment/Gender Affirming Surgery

Youth Services:

For mastectomy:

For members younger than 18 years of age, please see NOTE below;

(NOTE: Hormone therapy is not a pre-requisite.

According to the WPATH Standards of Care 7th Edition, "Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression.")

Policy Issued By: Independence Blue Cross

Policy Title: Treatment of Gender Dysphoria

Youth Services:

Puberty suppressing hormones (e.g., Supprelin LA® [histrelin acetate], Vantas® [histerlin acetate], Lupron Depot® [leuprolide acetate for depot suspension], Viadur® [leuprolide acetate implant], Eligard® [(leuprolide acetate for injectable suspension], Zoladex® [goserelin acetate implant], Trelstar® [triptorelin pamoate for injectable suspension]) are considered medically necessary and, therefore, covered, when all of the following criteria are met:

• The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed), in accordance with criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, [DSM-5].
• The individual has reached at least Tanner Stage 2 of development.
• Gender dysphoria emerged or worsened with the onset of puberty.

Note: Subject to the terms, conditions, and limitations of the member’s contract, oral and self-administered hormones are not covered under the medical benefit.

Policy Issued By: Louisiana Healthcare Connections (Centene Corporation - Medicaid)

Policy Title: Gender-Affirming Procedures

Youth Services:

Exception: in adolescent female to male patients < 18 years, chest surgery may be considered after one year of testosterone treatment;

Policy Issued By: Mass General Brigham Health Plan

Policy Title: Gender Affirming Procedures

Youth Services:

Mass General Brigham Health Plan will determine coverage of breast/chest surgeries specifically for transmasculine members under the age of 18 when all criteria specified above for gender affirming surgeries are met. These cases will be reviewed by a Medical Director for individual consideration

Policy Issued By: Neighborhood Health Plan of Rhode Island

Policy Title: Gender Dysphoria Treatment

Youth Services:

No authorization is required for behavioral and medical health.

Requires Authorization:

Services for Members Less than 18 Years of Age:

1. Pharmacological and hormonal therapy that is non-reversible and/or produces masculinization or feminization
2. Pharmacological and hormonal therapy to delay physical changes of puberty

Policy Issued By: Northeastern New York

Policy Title: Gonadotropin-Releasing Hormone Agonists

Youth Services:

Coverage for Lupron Depot®/Lupron Depot Ped® is provided for treatment of the following conditions:

• Gender dysphoria
• The diagnosis of gender dysphoria and the referral for hormone therapy have been made by a mental health professional in accordance with the WPATH criteria AND o The patient must be followed by an endocrinologist AND
• if used for suppression of puberty, therapy should not be started earlier than Tanner stage 2.

Policy Issued By: Oregon Health Authority (Oregon Health Plan)

Policy Title: Prioritized List of Health Services - Gender Dysphoria/Transsexualism

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).

Policy Issued By: Tufts Health Plan

Policy Title: Gender Affirming Services

Youth Services:

No age requirement listed for surgery.

Policy Issued By: UniCare (Anthem)

Policy Title: Gender Affirming Surgery

Youth Services:

A provider with experience treating adolescents with gender dysphoria may request further consideration of a gender affirming chest procedure case in an individual under 18 years old when they meet all other gender affirming chest procedure criteria above (including prior mental health evaluation) by contacting a Medical Director. (Further information is available in the Discussion/General Information section of this document titled ‘Gender Affirming Surgery in Individuals Under the Age of 18’).

Policy Issued By: UnitedHealthcare of California

Policy Title: Gender Dysphoria (Gender Identity Disorder) Treatment (California)

Youth Services:

Note: WPATH guidelines address age of majority in a given country. For the purposes of this guideline, the age of majority is age 18. However, this refers to chronological age and not biological age. Where approval or denial of benefits is based solely on the age of the individual a case-by-case medical director review is necessary.

Policy Issued By: WellPoint - UniCare

Policy Title: Gender Reassignment Surgery

Youth Services:

A provider with experience treating adolescents with gender dysphoria may request further consideration of a bilateral mastectomy case in an individual under 18 years old when they meet all other bilateral mastectomy criteria above (including prior mental health evaluation) by contacting a Medical Director.