Policy: Gender Reassignment Surgery
Policy Number: HS-317
Last Update: 2018-03-18

This policy applies to Medicaid

This policy applies to Medicare

Breast Reconstruction:

When all of the above criteria are met for gender reassignment surgery, the following genital surgeries may be considered for transwomen (male to female): ... Mammaplasty - breast augmentation

Covered CPT Codes – when criteria are met ... 19325 Mammaplasty, augmentation; with prosthetic implant

The following services and procedures are not a covered benefit: ... Breast augmentation (unless the individual has completed a minimum of 24 months of hormone therapy during which time breast growth has been negligible, or hormone therapy is medically contraindictated or the individual is otherwise unable to take hormones);

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.

Notes:

See also Gender Reassignment and Transgender Issues Clinical Practice Guideline HS-1059