Gender Dysphoria Treatment (for Ohio Only)
Defines medical necessity, covered and not medically necessary surgical and ancillary treatments for gender dysphoria for members in Ohio; identifies applicable clinical criteria (InterQual) and references Ohio Administrative Code for limits.
Surgical treatment for Gender Dysphoria is proven and medically necessary in certain circumstances; for medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Gender Affirmation Surgery.
A list of surgical procedures and therapies are explicitly listed as medically necessary and covered when criteria are met (e.g., bilateral mastectomy, vaginoplasty, phalloplasty, orchiectomy, hysterectomy, voice surgery/therapy, hair removal for genital reconstruction).
Certain ancillary procedures are considered cosmetic and not medically necessary when performed as part of surgical treatment for Gender Dysphoria (e.g., abdominoplasty, blepharoplasty, facial bone remodeling, hair transplantation, fillers, liposuction, rhinoplasty).
Definitions for Gender Dysphoria (children and adolescents/adults) and Qualified Healthcare Professional were added; Description of Services and Clinical Evidence sections were added/updated.
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