When ALL of the above criteria are met, the following may be considered medically necessary:
Coverage is subject to the specific terms of the member's benefit plan:
- Breast augmentation
- Chest masculinization
Note: Although not a requirement, it is recommended that individuals undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.
- Breast reconstruction (e.g., mastectomy)
- Penile prosthesis
- Reduction mammoplasty
- Testicular prosthesis implantation
Note: Penile prosthesis surgery is typically performed at stage two (2) or three (3) of a multi-stage phalloplasty (a minimum of nine (9) months following stage one (1)).
Reconstructive surgery, following gender affirmation surgery may be considered medically necessary when it is performed for ANY of the following reasons:
- Correct complications resulting from the initial surgery, or
- Correct a medical condition that resulted from the initial surgery that requires intervention, or
- Correct functional impairment resulting from initial surgery.
Reconstructive surgery following gender affirmation surgery to reverse natural signs of aging or if the individual is not satisfied with the aesthetic result is considered cosmetic and is not medically necessary.