Gender Affirming Surgical Care 

1. 1. These criteria refer to medically necessary gender affirming surgery including:
      • Gonadectomy
      • Genitalia reconstruction
      • Mastectomy for a transgender man (a person who has a gender identity as a man and who was assigned female at birth)
      • Augmentation mammoplasty (implants) for transgender women (a person who has a gender identity as a woman and who was assigned male at birth)
      • Thyroid reduction chondroplasty (tracheal shave)
      • Facial Feminization
      • Facial Masculinization
   2. Gender reassignment/affirming surgery, including pre- and post-surgical hormone therapy, is considered medically necessary when ALL of the following criteria are met:
      • Age 16 or older for breast surgery only, 18 or older for all other procedures listed below, AND
      • Has confirmed gender dysphoria diagnosed by counselor and treating physician, AND
      • Has capacity to make a fully informed decision and to consent for treatment AND
      • Has clearly demonstrated readiness for surgery confirmed by treating clinical professionals AND
      • Understands the effect of gender-affirming surgical intervention on reproduction and availability of other reproductive options AND
      • Mental health and physical conditions that could negatively impact the outcome of gender-affirming medical treatments have been assessed, with the risks and benefits discussed, before a decision is made regarding treatment; AND
      • A letter of recommendation for gender affirming surgery by qualified mental health professional with written documentation submitted to the physician performing the genital surgery AND
      • Documentation of at least 6-12 months of continuous hormonal gender affirming therapy (Trial of hormone therapy is not a pre-requisite to qualifying for a mastectomy)
   3. Gender affirming surgical interventions including facial, pelvic, gonadal and/or genital surgery and facial reconstruction for feminization or masculinization surgery  require a case by case review by the medical director and are based on review of detailed supporting documentation provided by the surgeon, with particular consideration given to the patient’s individual circumstances and needs and whether the proposed procedure(s) advance an individual’s ability to properly present and function in the identified gender role
   4. The procedures needed to reconstruct a feminine/masculine appearance can only be performed once per lifetime

Exclusions:

1. • Procedures associated with gender reassignment surgery that are performed solely for the purpose of improving or altering appearance or self-esteem related to one’s appearance are considered cosmetic in nature and not medically necessary.
   • All procedures that are not considered reconstructive by the multidisciplinary clinical team and/or not medically necessary and primarily cosmetic
   • Reversal of physical or functional outcomes due to gender affirming services.
   • Reversal of surgical procedures performed for gender affirming services.

Criteria based on Standards of Care for the Health of Transgender and Gender Diverse People, Version 8- 2022. World Professional Association for Transgender Health (WPATH)

Approved: 3/20

Reviewed: 5/21

Revised: 10/23