Policy Issued By: Aetna

Policy Title: Gender Affirming Surgery

Youth Services:

Mastectomy: members below the age of majority (less than 18 years of age), completion of one year of testosterone treatment;

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: AllWays Health Partners

Policy Title: Gender Affirming Procedures

Youth Services:

AllWays Health Partners will determine coverage of breast/chest surgeries specifically for FtM members under the age of 18 on a case by case basis, when all criteria specified above for gender affirming surgeries are met. (Commercial and Qualified Health Plans only).

Policy Issued By: Ambetter Peach State Health Plan (Centene Corporation)

Policy Title: Gender Affirming Surgery

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: Ambetter from Buckeye Health Plan (Centene Corporation)

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: Ambetter from Buckeye Health Plan (Centene Corporation)

Policy Title: Leuprolide Acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped)

Youth Services:

1. Diagnosis of gender dysphoria;
2. Request is not for Lupaneta Pack;
3. Prescribed by or in consultation with an endocrinologist and an expert in gender dysphoria and transgender medicine (e.g., mental health professional such as psychologist, psychiatrist);
4. Age and pubertal development - meets (a or b):
   1. Member has reached or passed through Tanner Stage 2* and is < 18 years of age; ______________*Age ranges approximating Tanner Stage 2 pubertal development extend from 8 to 13 years of age in girls and 9 to 14 years of age in boys.
   2. Member is ≥ 18 years of age and has failed to achieve physiologic hormone levels with gender-affirming hormonal therapy (e.g., estrogen, testosterone) unless contraindicated or clinically significant adverse effects are experienced;
5. Member demonstrates understanding of expected GnRH analogue treatment outcomes and has given consent for such treatment;
6. If member has a psychiatric comorbidity, member is followed by mental health provider;
7. Psychosocial support will be provided during treatment;
8. Dose is within FDA maximum limit for any FDA-approved indication or is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence).

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: AmeriHealth

Policy Title: Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)

Youth Services:

Leuprolide acetate for injection is considered medically necessary and, therefore, covered for puberty suppression 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].
• Gender dysphoria emerged or worsened with the onset of puberty.
• The individual has reached at least Tanner stage 2 of development.

Policy Issued By: AmeriHealth

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.

Policy Issued By: AmeriHealth Caritas of Louisiana

Policy Title: Gender Dysphoria

Youth Services:

The member is an adult age 18 or older, or documented as an emancipated adolescent, or has documentation of appropriate consent from parent or guardian.

Various hormones can be given to members not of majority age undergoing gender transformation.

Policy Issued By: Amerigroup (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: 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

Policy Title: Gonadotropin Releasing Hormone Analogs (GnRH) for the Treatment of Non-Oncologic Indications

Youth Services:

Requests for all GnRH Analogs—Zoladex (goserelin acetate), Vantas or Supprelin LA (histrelin acetate), Fensolvi, Lupron Depot or Lupron Depot-Ped, (leuprolide acetate), Lupaneta Pack (leuprolide acetate for depot suspension and norethindrone acetate tablets), Synarel Nasal Spray (nafarelin acetate), or Triptodur (triptorelin pamoate intramuscular extended release) may be approved if the following criteria are met:

I. Individual has a diagnosis of gender dysphoria in adolescents (Hembree 2009, 2017); AND

II. Individual fulfills the DSM V criteria for gender dysphoria (American Psychiatric Association 2013); AND

III. Individual has experienced puberty to at least Tanner stage 2 (Hembree 2009, 2017); AND

IV. Individual has (early) pubertal changes that have resulted in an increase of their gender dysphoria (Hembree 2009, 2017); AND

V. Individual does not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment (Hembree 2009, 2017); AND

VI. Individual has psychological and social support during treatment confirmed (Hembree 2009, 2017); AND

VII. Individual has confirmed to demonstrate knowledge and understanding of the expected outcomes of GnRH analog treatment (Hembree 2009, 2017).

Policy Issued By: Anthem

Policy Title: Testosterone, Injectable

Youth Services:

Testosterone injection are considered medically necessary for transgender individuals who meet ALL the following criteria:

1. Individual is 16 years of age or older; and
2. Individual has a diagnosis of gender dysphoria/incongruence or gender identity disorder; and
3. The goal of treatment is female-to-male gender reassignment.

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: Asuris

Policy Title: Transgender Services

Youth Services:

Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); and

No age restriction on hormones.

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 Federal Employee Program

Policy Title: Gonadotropin-Releasing Hormones (prior authorization policy)

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).

Policy Issued By: Blue Cross Blue Shield of Illinois

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 Kansas City

Policy Title: Treatment of Gender Dysphoria

Youth Services:

Age of majority in a given country. 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 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: Blue Cross Blue Shield of Massachusetts

Policy Title: Gender Affirming Services (Transgender Services)

Youth Services:

Puberty Blockers

Gonadotropin-releasing hormone (GnRH) analog treatment for gender non-conforming adolescents seeking to delay puberty is covered at the discretion of the treating provider*. GnRH analogs may be used to either allow patients more time for decision making purposes or as an initial step prior to further gender affirming services such as hormone replacement.

Treatment options include but are not limited to:

• Lupron
• Supprelin LA
• Vantas
• Triptodur (triptorelin).

Surgical Services for Adolescents

Members < 18 years of age will be considered on a case-by-case basis.

In addition to meeting all of the above criteria, providers requesting surgery for members < 18 will need to provide documentation supporting all of the following:

• The member has been evaluated for safety.
• The member has adequate home support.
• The member has realistic expectations regarding the possibilities and limitations of surgery and a full understanding of the long-term consequences of surgical procedures.
• The member has been assessed for any co-existing mental health concerns and is not requesting surgery as an initial response to gender dysphoric puberty.

Policy Issued By: Blue Cross Blue Shield of Montana

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 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 North Carolina

Policy Title: Gender Confirmation Surgery and Hormone Therapy

Youth Services:

Criteria for Adolescents Entering Puberty Adolescents, having reached puberty (Tanner 2), and who have met eligibility and readiness criteria can be treated with GnRH analogues. The definition of puberty is having reached Tanner stage 2/5 and/or having LH, estradiol levels or testosterone levels, within the pubertal range. These LH, estradiol and testosterone ranges are well-known and published and are broken down by biological male vs. biological female Tanner stage, and nocturnal and diurnal levels. Adolescents are eligible for GnRH treatment, (for suppression of puberty) by these criteria: (same for adults)

1. Have an established diagnosis for GD based on DSM V or ICD-10 criteria;

2. Have experienced puberty to at least Tanner stage 2, which can be confirmed by pubertal levels of LH, estrogen or testosterone; 3. Have experienced pubertal changes that resulted in an increase of their gender dysphoria;

4. Do not suffer from psychiatric comorbidity (that interferes with the diagnostic work-up or treatment);

5. Have adequate psychological and social support during treatment, to include having parental/guardian consent;

6. Demonstrate knowledge and understanding of the expected outcomes of GnRH analogue treatment, cross-sex hormone treatment, and gender affirmation surgeries, as well as the medical and social risks and benefits of gender affirmation; and have been counseled regarding fertility options.

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 Reassignment Surgery

Youth Services:

No age requirement for surgery.

Policy Issued By: Blue Cross Blue Shield of Vermont

Policy Title: Gender Reassignment Surgery for Gender Identity Disorder

Youth Services:

Initiation of feminizing/masculinizing hormone therapy, preferably for members under the age of 18 with parental or legal guardian consent, may be provided after a psychosocial assessment has been conducted and informed consent has been obtained by a health professional.

Exception to the age 18 criteria

Chest surgery in female to male individuals could be considered medically after one year of living in the desired gender role and one year of testosterone treatment. The intent of this sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery.

Additionally, for those under 18 years of age, the following must be submitted as evidence of puberty completion.*

* Evidence of puberty completion:

a) Documented tanner stage IV or V for members aged 15-18, and

b) Stable height measurements for 6 months, or

c) Puberty completion as shown on wrist radiograph

Policy Issued By: Blue Cross and Blue Shield of Florida

Policy Title: Gender Affirmation Surgery

Youth Services:

Must be 18 or older.

Policy Issued By: Blue Cross and Blue Shield of Florida

Policy Title: Gonadotropin Releasing Hormone Analogs and Antagonists

Youth Services:

Leuprolide acetate suspension for intramuscular depot administration (Lupron Depot 1-Month, Lupron Depot 3-Month, Lupron Depot 4- Month, Lupron Depot 6- Month)

1. Gender dysphoria [previously known as gender identity disorder (GID)] in adults meeting ALL of the following criteria:
   1. The member is 18 years of age or older
   2. The diagnosis of gender dysphoria (per DSM-V criteria for adolescents and adults) has been confirmed by a licensed mental health professional – documentation must be submitted
   3. Treatment will be used to reduce the member’s levels of endogenous hormones (e.g., testosterone or estrogen)
   4. The member is determined, by a licensed mental health professional, to have the capacity to make fully informed decisions and provide consent for treatment
   5. Any significant medical or mental health concerns (if present) are

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: BridgeSpan Health

Policy Title: Gender Affirming Interventions for Gender Dysphoria

Youth Services:

Age at least 18 years (Note: age requirement will not be applied to mastectomy with documented provider determination of medical necessity of earlier intervention); and

Policy Issued By: Capital BlueCross

Policy Title: GENDER AFFIRMING SURGERY (FORMERLY REASSIGNMENT SURGERY FOR GENDER DYSPHORIA)

Youth Services:

Individual consideration may be given to those under 18 years old wishing to undergo female to male chest surgery (see additional information in section below‡)

‡ Note: Per WPATH, chest surgery in Female to Male patients could be carried out prior to reaching the legal age of majority, 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.

Policy Issued By: CareFirst BlueCross BlueShield

Policy Title: Gender Affirmation Services /Gender Dysphoria

Youth Services:

Hormone therapy for individuals under the age of 18:

• For those without a medical contraindication to hormonal therapy, authorization of 12 months of hormone therapy is considered medically necessary for young adolescents with a diagnosis of gender dysphoria who are prescribed hormone therapy when ALL of the following criteria are met:
• Hormone therapy is prescribed for pubertal suppression for the treatment of gender dysphoria; and
• The individual has reached at least Tanner stage 2 of puberty.

Authorization of for continuation therapy must meet ALL initial authorization criteria.

Refer to CVS Caremark Specialty Guideline Management: Lupron Depot-PED and WPATH criteria Section VI.

Policy Issued By: Cigna

Policy Title: Treatment of Gender Dysphoria

Youth Services:

Medically necessary treatment for an individual with gender dysphoria may include ANY of the following services, when services are available in the benefit plan: ... Hormonal therapy, including but not limited to androgens, anti-androgens, GnRH analogues*, estrogens, and progestins (Prior authorization requirements may apply). *Note: If use in adolescents, individual should have reached Tanner stage 2 of puberty prior to receiving GnRH agonist therapy.

Policy Issued By: ConnectiCare

Policy Title: Gender Affirming/Reassignment Surgery (Commercial)

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: 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: EmblemHealth - New York

Policy Title: Gender Affirming/Reassignment Surgery - New York

Youth Services:

1. Treatment with gonadotropin-releasing hormone agents (pubertal suppressants) when based upon a determination by a qualified medical professional that the member is eligible and ready for such treatment, i.e., that the member:
   1. Meets gender dysphoria diagnostic criteria
   2. Has experienced puberty to at least Tanner stage 2 with pubertal changes resulting in increased gender dysphoria
   3. Does not suffer from psychiatric comorbidity that interferes with diagnostic work-up or treatment
   4. Has adequate psychological and social support during treatment
   5. Demonstrates knowledge and understanding of expected treatment-outcomes associated with pubertal suppressants and cross-sex hormones, as well as the medical and social risks and benefits of sex reassignment
2. 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.

Requests for gender reassignment surgery for members less than 18 years will be reviewed on a case-by-case basis.

Policy Issued By: Empire Blue Cross Blue Shield (Anthem)

Policy Title: Gender Affirming Surgery

Youth Services:

Further Considerations:

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’).

Gender Affirming Chest Surgery in Individuals Under the Age of 18 (Return to Clinical Indications)

Further consideration of a gender affirming chest procedure in select individuals under 18 years of age may be appropriate; there may exist extenuating circumstances, such as the level of maturity of the individual, duration of dysphoric symptoms, medical and mental health, and other factors, that should be considered in consultation with a provider with experience treating adolescents with gender dysphoria. The WPATH SOC provides the following guidance for individuals under the age of 18:

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 their gender identity. The age threshold should be seen as a minimum criterion and not an indication in and of itself for active intervention.

Chest surgery in FtM 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: Excellus Blue Cross Blue Shield

Policy Title: Gender Reassignment/Gender Affirming Surgery and Treatments

Youth Services:

Based upon our criteria and assessment of the peer-reviewed literature, hormone therapy (i.e., gonadotropin-releasing hormone agents/pubertal suppressants and cross-sex hormones), with the exception of histrelin acetate (See Policy Statement XI) has been shown to be a beneficial and effective intervention for gender dysphoria, and, therefore, is considered medically appropriate (refer to Policy Guideline I).

[For mastectomy] if under the age of majority, meets all of the following criteria for early intervention:

1. has consent from both parents/guardians for surgery when applicable;
2. has identified as transgender for at least two years;
3. has been living in the desired gender role for at least one year;
4. has been receiving testosterone treatment for at least one year;
5. has received an additional letter of referral from a second qualified mental health professional or physician (refer to Policy Guidelines below);
6. has compelling reasons impacting their physical and/or psychological well-being, as documented by the patient’s mental health/adolescent medicine provider(s); and
7. has reasonably good control over any significant medical or mental health concerns that are present.

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: Geisinger Health Plan

Policy Title: Gender Dysphoria and Gender Confirmation Treatment

Youth Services:

Peri-pubertal – gonadotropin-releasing hormone (GnRH) analogs to achieve suppression of pubertal hormones may be considered once the member reaches Tanner Stage* 2

*The Tanner Scale is measurement of physical development in children, adolescents and adults.

http://www.childgrowthfoundation.org/CMS/FILES/Puberty_and_the_Tanner_Stages.pdf

• Between 14 – 16 yrs of age –pubertal development of the desired opposite sex can be using a gradually increasing dose schedule of cross-gender hormone.

• Adolescents should be treated with GnRH analogues, progestins (e.g., medroxyprogesterone) or other medications that block and/or neutralize testosterone, estrogens and progesterone secretion.

Surgical Treatment

Per WPATH guidelines, “Chest surgery in FtM 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: HMSA

Policy Title: Gender Identity Services

Youth Services:

Puberty suppression therapy is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. The patient has been diagnosed with persistent, well-documented gender dysphoria as defined by the current Diagnostic and Statistical Manual of Mental Disorders(DSM) criteria (see Appendix B) and gender identity disorder as defined by the current International Classification of Diseases(ICD) criteria by a qualified mental health professional (see Appendix A);
2. The patient has exhibited the first physical changes of puberty, indicated by a minimum Tanner stage of 2;
3. The patient has completed at least three months of successful continuous full time real-life experience in their gender identity across a wide span of life experiences and events (e.g., holidays, vacations, season-specific school and/or work experience, family events);
4. Clinical records document that the patient assents to treatment and the parent/guardian has made a fully informed decision and consent to treatment;
5. The patient’s comorbid medical and mental health conditions(if present) are reasonably well-controlled; and
6. Puberty suppression therapy will be administered in a safe, appropriate, medically supervised manner.

Continuous hormone replacement therapy is covered ... when ... the patient is at least 16 years of age; if the candidate is less than 16 years of age, then treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet this criterion.

Breast/chest surgery: subcutaneous mastectomy, creation of a male chest; including nipple reconstruction (if appropriate) is covered (subject to Limitations and Administrative Guidelines) when ... the patient is at least 16 years of age; if the candidate is less than 16 years of age, then treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet this criterion.

Policy Issued By: Harvard Pilgrim Health Care

Policy Title: Transgender Health Services

Youth Services:

Surgical Services for Adolescents - Consideration for breast and chest surgery (e.g. nipple areola reconstruction, mastectomy, breast augmentation) will be given to trans-adolescents under the age of 18 who meet all other policy criteria

Policy Issued By: Hawaii Medical Service Association

Policy Title: Gender Identity Services

Youth Services:

Subcutaneous mastectomy, creation of a male chest for transmasculine individuals; including nipple reconstruction (if appropriate) is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. The patient is at least 16 years of age; if the candidate is less than 16 years of age, then treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet this criterion.
2. The patient has been diagnosed with persistent, well-documented gender dysphoria as defined by the current DSM criteria (see Appendix B) and gender identity disorder as defined by the current ICD criteria by a qualified health professional (see Appendix A);
3. Clinical records document that the patient has made a fully informed decision and consents to treatment or (if under age 18) assents to treatment and a parent/guardian consents to treatment;
4. The patient’s comorbid medical and mental health conditions (if present) are reasonably well-controlled; and
5. The patient has obtained a referral letter from a qualified mental health professional (see Appendix A).

Puberty suppression therapy is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. The patient has been diagnosed with persistent, well-documented gender dysphoria as defined by the current Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria (see Appendix B) and gender identity disorder as defined by the current International Classification of Diseases (ICD) criteria by a qualified health professional (see Appendix A);
2. The patient has exhibited the first physical changes of puberty, indicated by a minimum Tanner stage of 2
3. Clinical records document that the patient assents to treatment and the parent/guardian has made a fully informed decision and consents to treatment;
4. The patient’s comorbid medical and mental health conditions (if present) are reasonably well-controlled; and
5. Puberty suppression therapy will be administered in a safe, appropriate, medically supervised manner.

Continuous hormone replacement therapy is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. The patient is at least 16 years of age; if the candidate is less than 16 years of age, then treating clinician must submit information indicating why it would be clinically inappropriate to require the candidate to meet this criterion.
2. The patient has been diagnosed with persistent, well-documented gender dysphoria as defined by the current DSM criteria (see Appendix B) and gender identity disorder as defined by the current ICD criteria by a qualified health professional (see Appendix A);
3. Clinical records document that the patient has made a fully informed decision and (if at least age 18) consents to treatment or (if under age 18) assents to treatment and a parent/guardian consents to treatment;
4. The patient’s comorbid medical and mental health conditions (if present) are reasonably well-controlled; and
5. Continuous hormone replacement therapy will be administered in a safe, appropriate, medically supervised manner.

Policy Issued By: Health Net

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: HealthPartners

Policy Title: Gender Reassignment Surgery

Youth Services:

No age requirement for surgery.

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: Highmark Blue Cross Blue Shield (Pennsylvania)

Policy Title: Testosterone Androgens

Youth Services:

Testosterone injections may be considered medically necessary for transgender individuals who meet ALL the following:

• Individual is 14 years of age or older; and
• Individual has a diagnosis of gender dysphoria or gender identity disorder; and
• The goal of treatment is masculinization.

Policy Issued By: Highmark Blue Cross Blue Shield Delaware

Policy Title: Testosterone Androgens

Youth Services:

Testosterone injections may be considered medically necessary for transgender individuals who meet ALL the following:

• Individual is  14 years of age or older; and
• Individual has a diagnosis of gender dysphoria or gender identity disorder; and
• The goal of treatment is masculinization.

Policy Issued By: Highmark Delaware

Policy Title: Gonadotropin Releasing Hormones (GnRHs) Analogs

Youth Services:

The use of histrelin acetate (Supprelin LA, Vantas), leuprolide acetate (Lupron Depot, Lupron Depot-Ped Fensolvi), or triptorelin (Triptodur, Trelstar) may be considered medically necessary for puberty suppression in individuals with gender dysphoria when ALL of the following criteria are met:

Policy Issued By: Highmark Delaware

Policy Title: Gonadotropin Releasing Hormones (GnRHs) Analogs

Youth Services:

The use of histrelin acetate (Supprelin LA, Vantas), leuprolide acetate (Lupron Depot, Lupron Depot-Ped Fensolvi), or triptorelin (Triptodur, Trelstar) may be considered medically necessary for puberty suppression in individuals with gender dysphoria when ALL of the following criteria are met:

Policy Issued By: Highmark West Virginia

Policy Title: Testosterone Androgens

Youth Services:

Testosterone injections may be considered medically necessary for transgender individuals who meet ALL the following:

• Individual is 14 years of age or older; and
• Individual has a diagnosis of gender dysphoria or gender identity disorder; and
• The goal of treatment is masculinization.

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: Johns Hopkins Healthcare

Policy Title: Gender Affirmation Treatment & Procedures

Youth Services:

Hormones under 18: For individuals under the age of 18, screening for the presence of the diagnosis of Gender Dysphoria and for medical and mental health issues must be completed by two qualified health professionals, one of whom must be a physician.

Policy Issued By: Kaiser Foundation Health Plan of Washington

Policy Title: Gender Reassignment Surgery

Youth Services:

Requirements for Mastectomy (i.e., initial mastectomy, with nipple sparing or tattooing) for female-to-male patients. Member must meet ALL of the following: A. Age 18 years or older (Note: age requirement will not be applied to mastectomy in Female-to-Male patients if the surgeon, the primary care provider, and the qualified mental health professional unanimously document the medical necessity of earlier intervention)

Requirements for breast augmentation for male-to-female members: ... Age 18 years or older (Note: age requirement will not be applied to augmentation in Male-toFemale patients if the surgeon, the primary care provider, and the qualified mental health professional unanimously document the medical necessity of earlier intervention)

Policy Issued By: Kaiser Permanente Northwest Region

Policy Title: Transgender Surgery

Youth Services:

For FtM members under the age of 18, chest surgery can be carried out on adolescents 16 years or older after ample time of living in the desired gender role and after one year of testosterone treatment. Adolescent FtM patients seeking chest surgery must also meet criteria 2-6 above and must have parental consent or be legally emancipated.

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: Moda Health Plan

Policy Title: Gender Confirming Surgery

Youth Services:

Reversible therapy with puberty-suppressing hormones are medically appropriate with ALL of the following:

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. The member has experienced the onset of puberty to at least Tanner Stage 2.
4. Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g. may compromise adherence with treatment) have been addressed such that the adolescent’s situation and functioning are stable enough to start treatment
5. 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.

Chest surgery in FtM adolescent patients may be carried out prior to 18 with ALL of the following:

1. Meets all of the criteria for treatment of adolescent with puberty-suppressing hormones and masculinizing hormones
2. Reached the age of medical consent
3. Had ample time (preferably one year) living in the desired gender role
4. Undergone one year of testosterone treatment.

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: Optimum HealthCare, Inc.

Policy Title: Testosterone

Youth Services:

NP Topical Androgens - For transgender use, individual is 16 years of age or older.

Testosterone Injections - no age restriction.

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: Prestige Health Choice

Policy Title: Gender Dysphoria

Youth Services:

Adolescents. Various hormones can be given to members not of majority age undergoing gender transformation. Similar to adults, the specific hormones vary by individual, but often serve to suppress puberty in the member’s birth gender. All cases must observe the following criteria:

1. The member has a long-lasting and intense pattern of gender nonconformity or dysphoria.
2. Gender dysphoria emerged or worsened with the onset of puberty.
3. Any co-existing psychological, social, or medical problems that could interfere with treatment have been addressed, and the member’s condition is stable.
4. The member has given informed consent, or (if not of age) parents, other caretakers, or guardians have consented to treatment and are involved in the treatment process.

Policy Issued By: Tufts Health Plan

Policy Title: Transgender Surgical Procedures

Youth Services:

No age requirement listed for surgery.

Policy Issued By: UPMC Health Plan

Policy Title: Gender Affirmation Surgery

Youth Services:

Minimum 18 years of age or on a case by case basis, the minimum age of 18 years may be reconsidered for mastectomy surgeries if sufficient documentation is provided, all other criteria have been met, and the presence of the breasts precludes the patient from successfully adopting a male or androgynous gender role.

Medicaid plans: For feminizing breast/chest surgery, patients younger than 18 years of age will be reviewed by a Medical Director.

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: Uniform Medical Plan Uniform Medical Plan (Washington State Health Care Authority)

Policy Title: Gender Affirming Interventions for Gender Dysphoria: Clinical Criteria and Policy

Youth Services:

For patients younger than 18 years of age, mastectomy may be considered a medically necessary surgical procedures. Other requirements outlined in this section must be met to proceed with mastectomy in those younger than 18 years of age.

Policy Issued By: UnitedHealthcare Oxford

Policy Title: Gonadotropin Releasing Hormone Analogs

Youth Services:

Gender Dysphoria in Adolescents:

GnRH analogs may be covered for the treatment of Gender Dysphoria when ALL of the following criteria are met:

For initial therapy, submission of medical records (e.g., chart notes, laboratory values) documenting all the following:

• Diagnosis of gender dysphoria, according to the current DSM (i.e., DSM-5) criteria, by a mental health professional with expertise in child and adolescent psychiatry; and
• Medication is prescribed by or in consultation with a pediatric endocrinologist or by a physician working in a multidisciplinary clinic for transgender youth; and
• Patient has experienced puberty development to at least Tanner stage 2 (stage 2 through 4); and
• One of the following laboratory tests, based upon the laboratory reference range, confirming:
  • Pubertal levels of estradiol in females; or
  • Pubertal levels of testosterone in males; or
  • Pubertal basal level of luteinizing hormone (based on laboratory reference ranges); or
  • A pubertal luteinizing hormone response to a GnRH stimulation test; and
  • A letter from the prescriber and/or formal documentation stating all of the following:
    • Patient has experienced pubertal changes that have resulted in an increase of their gender dysphoria that has significantly impaired psychological or social functioning; and
    • Coexisting psychiatric and medical comorbidities or social problems, that may interfere with the diagnostic
    • procedures or treatment, have been addressed or removed; and
    • Both of the following:
      • Current enrollment, attendance, and active participation in psychological and social support treatment program; and
      • Patient will continue enrollment, attendance and active participation in psychological and social support throughout the course of treatment; and
    • Patient demonstrates knowledge and understanding of the expected outcomes of treatment and related transgender therapies; and
    • Initial authorization will be for no longer than 12 months.

For continuation therapy, submission of medical records (e.g., chart notes, laboratory values) documenting all the following:

• Documentation of LH suppression using a GnRH stimulation test
• Documented diagnosis of gender dysphoria, according to the current DSM (i.e., DSM-5) criteria, by a mental health professional with expertise in child and adolescent psychiatry; and
• Medication is prescribed by or in consultation with a pediatric endocrinologist or by a physician working in a multidisciplinary clinic for transgender youth; and
• A letter from the prescriber and/or formal documentation stating all of the following:
  • Patient continues to meet their individual goals of therapy for gender dysphoria; and
  • Patient continues to have a strong affinity for the desired (opposite of natal) gender; and
  • Discontinuation of treatment and subsequent pubertal development would interfere with or impair psychological functioning and well-being; and
  • Coexisting psychiatric and medical comorbidities or social problems that may interfere with treatment continue to be addressed or removed; and
  • Both of the following:
    • Current enrollment, attendance, and active participation in psychological and social support treatment program; and
    • Patient will continue enrollment, attendance and active participation in psychological and social support throughout the course of treatment and
• Patient demonstrates knowledge and understanding of the expected outcomes of treatment and related transgender therapies; and
• Reauthorization will be for no longer than 12 months.

Note: Clinical evidence supporting the use of GnRH analogs for the treatment of gender dysphoria is limited and lacks long-term safety data. Statistically robust randomized controlled trials are needed to address the issue of whether the benefits outweigh the clinical risk in its use.

Policy Issued By: UnitedHealthcare Oxford

Policy Title: Prior Authorization/Medical Necessity – Topical Androgens

Youth Services:

No age restriction for testosterone.

Policy Issued By: UnitedHealthcare West

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

Youth Services:

Coverage is available for medical, behavioral or pharmacological treatment that is Medically Necessary for Gender Dysphoria. UnitedHealthcare does not exclude or deny covered health care benefits based on associated diagnosis of Gender Dysphoria, or otherwise discriminate against the member on the basis that treatment is for Gender Dysphoria.

Policy Issued By: UnitedHealthcare West

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

Youth Services:

Coverage is available for medical, behavioral or pharmacological treatment that is Medically Necessary for Gender Dysphoria. UnitedHealthcare does not exclude or deny covered health care benefits based on associated diagnosis of Gender Dysphoria, or otherwise discriminate against the member on the basis that treatment is for Gender Dysphoria.

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: Univera Healthcare

Policy Title: Gender Reassignment/Gender Affirming Surgery and Treatments for Medicaid Managed Care Plan (MMCP) and Health and Recovery Plan (HARP) Members

Youth Services:

Bilateral mastectomy: The patient has reached the age of majority (18 years of age or older), or, if under the age of majority, meets all of the following criteria for early intervention:

1. has consent from parent(s)/guardian(s) for surgery; and
2. has identified as transgender for at least two years; and
3. has been living in the desired gender role for at least one year; and
4. has been receiving testosterone treatment for at least one year; and
5. has received an additional letter of referral from a second qualified mental health professional or physician (refer to Policy Guidelines below); and
6. has compelling reasons impacting their physical and/or psychological well-being, as documented by the patient’s mental health/adolescent medicine provider(s); and
7. any significant medical or mental health concerns that are present are reasonably well controlled.

Policy Issued By: University Health Alliance

Policy Title: Gender Identity Services

Youth Services:

Puberty suppression therapy is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. The patient has been diagnosed with persistent, well-documented gender dysphoria as defined by the current Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria (see Appendix B) and gender identity disorder as defined by the current International Classification of Diseases (ICD) criteria by a qualified mental health professional (see Appendix A);
2. The patient has exhibited the first physical changes of puberty, indicated by a minimum Tanner stage of 2 or 3;
3. The patient has completed at least three months of successful continuous full time real-life experience in their gender identity across a wide span of life experiences and events (e.g., holidays, vacations, season-specific school and/or work experience, family events);
4. Clinical records document that the patient assents to treatment and the parent/guardian has made a fully informed decision and consents to treatment;
5. The patient’s comorbid medical and mental health conditions (if present) are reasonably well-controlled; and
6. Puberty suppression therapy will be administered in a safe, appropriate, medically supervised manner.

Continuous hormone replacement therapy is covered (subject to Limitations and Administrative Guidelines) when all of the following criteria are met:

1. The patient is at least 16 years of age;

Policy Issued By: WellCare

Policy Title: Gender Reassignment Surgery

Youth Services:

Gonadotropin-releasing hormone is considered medically necessary to suppress puberty in trans identified adolescents if they meet World Professional Association for Transgender Health (WPATH) criteria:

• Adolescent has demonstrated a long-lasting and intense pattern of gender non-conformity or gender dysphoria (whether suppressed or expressed); AND
• Gender dysphoria emerged or worsened with the onset of puberty; AND
• Any co-existing 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
• 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: 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.

Policy Issued By: Wellmark Blue Cross Blue Shield

Policy Title: Testosterone – Topical/Buccal/Nasal/Oral

Youth Services:

• The requested drug is being prescribed for female-to-male gender reassignment
• The member is 14 years of age or older and able to make an informed, mature decision to engage in therapy