Skip to main content

Keyboard Shortcuts

Key Pair Function
Alt S Search Box
Alt T Top of Page
Alt H Home Page
Alt Index Button
Alt Next Button
Alt Prev Button
TLDEF Logo

TLDEF's Trans Health Project

Working for Transgender Equal Rights
Menu
  • Trans Health Insurance Tutorial
    • Choosing a Plan
    • Understanding Your Plan
    • Applying for Coverage
    • Understanding a Denial
    • Appealing a Denial
  • Resources
    • Health Insurance Medical Policies
    • Medical Organization Statements
    • State Health Insurance Laws and Guidance
    • Medicaid Regulations and Guidance
    • Gender Centers
    • Trans Health Care Providers
    • State Employee Health Plans
    • Financial Aid for Transgender Surgeries
  • Tools
    • Legal Analysis
    • Medical Necessity Literature Reviews
    • Reporting Medical Provider Discrimination
    • Training Materials for Advocates
    • Appealing Medical Necessity Denials
    • Provider Medical Necessity Letter Checklists
  • About Us
    • About TLDEF's Trans Health Project
    • Privacy Policy
  • Contact Us
    • Contact TLDEF's Trans Health Project
    • Contact TLDEF
Previous Page
Prev
Home
Home
Up
Up
Next Page
Next
  •  Home
  • Tools
  • Provider Medical Necessity Letter Checklists
  • Current: Facial surgery for gender dysphoria - Hormone provider or surgeon checklist

Facial surgery for gender dysphoria - Hormone provider or surgeon checklist

Use this checklist to ensure that each element is included in your letter. Use language that is client specific; do not simply copy this checklist.


Download PDF

Identification of the procedure and diagnosis (per WPATH SOC p. 28)

  • The duration of the provider’s relationship with the patient
  • That the patient has gender dysphoria
  • Procedure needed

Hormone use

  • What hormone therapy the patient is on
  • Date started and length of time on hormones
  • That the patient takes the hormones consistently and appropriately
  • Limits of hormones on ability to change facial features
  • That hormone therapy has been insufficient to change the shape of her face to alleviate gender dysphoria

Face dysphoria

  • Any complaints that the patient has stated about her face or misgendering
  • Describe facial features that are typically male
  • Surgeon: describe how the specific procedures will change those features from male to female

Capacity to make a fully informed decision and to consent for treatment

  • Patient has capacity to make a fully informed decision
  • Patient has provided informed consent for surgery (if you have discussed it with them)

Statement of medical necessity

  • Indicate if you recommend surgery
  • If you find it to be accurate, use the phrase “medically necessary,” which is defined in insurance policies simply to mean clinically appropriate care to treat a condition in accordance with generally recognized standards of care
  • Indicate if the surgery is undertaken for the purpose of treating gender dysphoria and will help to alleviate the person’s gender dysphoria
  • If you have seen this surgery help other trans patients, note that

State the qualifications of the provider

Discuss your credentials as applicable. Omit things that do not apply.
  • Education and degree
  • Licensure
  • Length of time & experience working with/diagnosing trans patients
  • Number/percentage of trans patients seen, if a significant part of your practice
  • Continuing education in the assessment and treatment of gender dysphoria;
  • Relevant professional associations
  • Relevant publications
  • Relevant trainings given, courses taught
  • Consider attaching CV if a specialist

If you need any additional information, please do not hesitate to contact me at [phone].

Sincerely,

Signature
Provider’s Name
Licensing information

Back to top

Updated on Nov 19, 2020

Donate Now - Secure donations through Network for Good Donate Now

Join Our Mailing List

Facebook Button Twitter Button
 Keyboard Shortcuts
 Privacy Policy
 TLDEF Website

Copyright © 2021 Transgender Legal Defense & Education Fund, Inc.  |  520 8th Avenue, Suite 2204, New York, NY 10018   Tel: 646.862.9396   Fax: 646.993.1684