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priorityhealth medical policy 91612 (pdf)
https://www.priorityhealth.com/provider/manual/auths/~/media/documents/medical-policies/91612.pdfMEDICAL POLICY No. 91612-R0
GENDER REASSIGNMENT SURGERY FOR MEDICARE MEMBERS
Effective Date: January 1, 2016
Date Of Origin: August 12, 2015
I. POLICY/CRITERIA
Gender reassignment surgery, including pre- and post-surgical hormone
therapy, is considered medically necessary when ALL of the following criteria
are met:
1) age 18 or older, AND
2) has confirmed gender dysphoria, AND
3) is an active participant in a recognized gender identity treatment program,
AND
4) capacity to make a fully informed decision and to consent for treatment.
If medically necessary criteria for coverage for gender reassignment surgery are
met, the following conditions of coverage apply. ...
(pdf)