Transgender / gender-affirming service request review (APL 20-018)
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Describes how MemorialCare Select Health Plan will evaluate transgender service requests per DHCS All Plan Letter APL 20-018, affecting physicians and participating physician groups (PPGs) and, for Medi-Cal, specified counties.
Plans must analyze transgender service requests under both the applicable medical necessity standard for gender dysphoria and the statutory criteria for reconstructive surgery.
If medical necessity for gender dysphoria is not established, the request must still be considered against reconstructive surgery criteria taking into account the member's identified gender.
Requests should be supported by evidence from the member's PCP, licensed mental health professional, and/or experienced surgeon.
Coverage Criteria
Approval criteria (dual pathways)
Covered when EITHER of the following independent paths is met:
Approval on this basis requires sufficient supporting clinical documentation.
A finding that these legal criteria are met is an independent basis for approval even if medical necessity for gender dysphoria is not established.
No explicit exclusions are listed in this document.
If a requested transgender-related service is determined not to be medically needed to treat gender dysphoria, and the request also does not meet the statutory reconstructive surgery criteria, the service is not approved. When medical necessity for gender dysphoria cannot be established due to insufficient information, the request must still be evaluated against the reconstructive surgery criteria before a denial is issued.
Coding
| No codes listed |
Provider Actions & Documentation
Dual-path prior authorization review
Per DHCS APL 20-018, evaluate every transgender service request along two independent pathways: (1) whether the service is medically necessary to treat the member's gender dysphoria, and (2) whether the service meets the statutory criteria for reconstructive surgery. A finding on either pathway is a separate basis for approval.
- Apply both the applicable medical necessity standard for gender dysphoria and the statutory reconstructive surgery criteria to each request.
- Approval may be based on a determination of medical necessity OR a determination that the reconstructive surgery criteria are met.
Provider review must use both approval pathways
Ensure the plan's review process applies the dual-path analysis required by DHCS: do not deny solely for lack of gender dysphoria documentation without also evaluating the reconstructive surgery criteria in light of the member's identified gender.
- If medical necessity for gender dysphoria is not established or documentation is insufficient, still assess whether statutory reconstructive surgery criteria are met.
- A positive finding on either pathway independently justifies approval.
Required supporting documentation
Include supporting clinical evidence with the request. Documentation should come from the member's primary care provider, a licensed mental health professional, and/or a surgeon qualified and experienced in transgender health care to demonstrate medical necessity or that reconstructive surgery criteria are met.
- Send PCP documentation when relevant to medical necessity or surgical need.
- Include assessment or letters from a licensed mental health professional when supporting gender dysphoria treatment.
- Attach surgeon documentation when asserting that reconstructive surgery criteria are met.
Denial triggers if neither approval pathway is met
A request may be denied if neither medical necessity for gender dysphoria nor the statutory reconstructive surgery criteria are demonstrated or supported by the submitted documentation.
- Denial risk applies when documentation is insufficient to establish medical necessity and the reconstructive surgery criteria are not shown to be met.
Definitions
Background
Per DHCS All Plan Letter APL 20-018, health plans must evaluate transgender-related service requests using two independent bases for approval: a finding that the service is medically needed to treat the member's gender dysphoria, or a finding that the service meets the statutory criteria for reconstructive surgery. A positive determination on either basis authorizes the service, and plans must consider both pathways when reviewing requests.
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