Policy: Gender Dysphoria Treatment
Policy Number: 0266
Last Update: 2023-08-15

Breast Reconstruction:

Initial breast reconstruction including augmentation with implants is covered.

Permanent Hair Removal:

Hair removal is not covered unless related to genital surgery.

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