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Effective January 1, 2016, gender dysphoria services, including gender reassignment surgery (GRS), may be covered when medically necessary and if the individual meets all criteria.
A predetermination of benefits must be submitted to evaluate medical necessity or medical appropriateness of the proposed treatment. If there is a discrepancy between the Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
The individual being considered for GRS surgery must meet all the following criteria. The individual must have:
Note regarding mental health services: If the first referral is from the individual's psychotherapist, the second referral should be from a clinician who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (if both are practicing within the same clinic or program), may be sent. Psychotherapy is not required for GRS except when the mental health professional's initial assessment recommends psychotherapy that specifies the goals of treatment and estimates its frequency and duration throughout the real life experience.
Primary Sexual Characteristic Gender Reassignment Chest and/or Genital Surgeries:
Male-to-Female (MtF) surgical procedures performed as part of gender reassignment services for an individual who has met the above criteria for gender dysphoria may be considered medically necessary and include the following:
Female-to-Male (FtM) surgical procedures performed as part of gender reassignment services for an individual who has met the above criteria for gender dysphoria may be considered medically necessary and include the following:
Secondary Sexual Characteristic (Masculinizing or Feminizing) Gender Reassignment Surgeries and Related Services:
Procedures or services to create and maintain gender specific characteristics (masculinization or feminization) as part of the overall desired gender reassignment services treatment plan may be considered medically necessary for the treatment of gender dysphoria ONLY. These procedures may include the following:
Gender specific preventive medicine services may be covered for GRS individuals who are planning to undergo or have undergone GRS: