- Physicians (does not apply to Cal MediConnect)
- Participating Physician Groups (PPG)
The U.S Department of Health and Human Services (HHS) invalidated Medicare's National Coverage Determination (NCD) Manual, Section 140.3, Transsexual Surgery (effective May 30, 2014). Accordingly, its provisions are no longer a basis for denying claims for Cal Medi-Connect (Medicare Advantage based) coverage of transgender services.
Health Net is required to consider whether claims for CalMedi-Connect transgender services are reasonable and necessary as defined in the Social Security Act, Section 1862(a)(1)(A). In the absence of a documented NCD or Local Coverage Determination (LCD), Health Net applies evidence-based clinical criteria in determining medical necessity of requested services. Refer to Health Net's Gender Reassignment Surgery medical policy for clinical criteria located on the Health Net provider portal under Working with Health Net > Clinical > Medical Policies.
Medically necessary transgender services for treatment of gender identity disorder (GID) are covered benefits for Cal MediConnect members. Transgender services refer to the treatment of GID, which may include the following:
- consultation with transgender service providers
- transgender services work-up and preparation
- continuous hormonal therapy
- laboratory testing to monitor hormone therapy
- gender reassignment surgery that is not cosmetic in nature
Medically Necessary/Reconstructive Surgery
No categorical exclusions or limitations apply to coverage for the treatment of GID. Each of the following procedures, when used specifically to improve the appearance of an individual undergoing gender reassignment surgery or actively participating in a documented gender reassignment surgery treatment plan, must be evaluated to determine if it is medically necessary reconstructive surgery to create a normal appearance for the gender with which the member identifies. Prior to making a clinical determination of coverage, it may be necessary to consult with a qualified and licensed mental health professional and the treating surgeon.
- Breast augmentation
- Facial bone reduction
- Facial feminization
- Hair removal
- Hair transplantation
- Reduction thyroid chondroplasty
- Subcutaneous mastectomy
- Voice modification surgery
Cosmetic procedures are excluded from coverage. Coverage is subject to prior authorization based on medical necessity.
This section clarifies how Health Net administers benefits in accordance with the World Professional Association for Transgender Health (WPATH), Standards of Care (SOC), Version 7. Provided a patient has been properly diagnosed with gender dysphoria or GID by a mental health professional or other provider type with appropriate training in behavioral health and competencies to conduct an assessment of gender dysphoria or GID, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy, certain options for social support and changes in gender expression are considered to help alleviate gender dysphoria or GID.
For example, with respect to hair removal through electrolysis, laser treatment, or waxing, the WPATH "Statement of Medical Necessity for Electrolysis" (July 15, 2016) clarifies that patients with the same condition do not always respond to, or thrive, following the application of identical treatments. Treatment must be individualized, such as with electrolysis, and medical necessity should be determined according to the judgment of a qualified mental health professional and referring physician. The documentation to support the medical necessity for hair removal should include three essential elements:
- A properly trained (in behavioral health) and competent (in assessment of gender dysphoria) professional has diagnosed the member with gender dysphoria or GID.
- The individual is under feminizing hormonal therapy.
- The medical necessity for electrolysis has been determined according to the judgment of a qualified mental health professional and the referring physician.
If any element remains to be satisfied before medical necessity can be determined, the individual should be directed to an appropriate network participating provider for consultation or treatment.
Prior authorization is required for transgender services. Providers must submit clinically relevant information for medical necessity review with the prior authorization request.
Providers Participating through PPGs
Providers participating through PPGs must contact their PPGs' prior authorization process and use the PPG's forms. PPGs are responsible for authorizing GID services.