20-1015 Stay Current on Transgender Service Request Rules
Date: 12/17/20
This information applies to Physicians and Participating Physician Groups (PPGs).
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
DHCS has released new guidelines
Per All Plan Letter (APL) 20-018, from the Department of Health Care Services (DHCS), effective October 26, 2020, all plans and their participating physician groups (PPGs) must analyze transgender service requests under both:
- The applicable medical necessity standard for services to treat gender dysphoria and
- The statutory criteria for reconstructive surgery.
A finding of either “medically necessary to treat gender dysphoria” or “meets the statutory criteria of reconstructive surgery” serves as a separate basis for approving the request.
Medical necessity determination
If it is determined that the service is medically needed to treat the member’s gender dysphoria, it must be approved.
If it is determined the service is not medically needed to treat gender dysphoria (or if there is not enough information to establish medical necessity), it must still be considered whether the service meets the criteria for reconstructive surgery, taking into consideration the gender with which the member identifies.
Provide supporting evidence
The request for transgender services should be supported by evidence of either medical necessity or evidence supporting the requirement for reconstructive surgery.
Supporting documentation should be sent, as appropriate, by the member’s primary care provider, licensed mental health professional, and/or surgeon who are qualified and have experience in transgender health care.
Additional Information
For additional information refer to DHCS APL 20-018 (PDF).
For all other questions, contact the Health Net Medi-Cal Provider Services Center within 60 days at 1-800-675-6110.