Update to Prior Authorizations (PA) for Gender Affirming Medical and Surgical Treatment​

Apr 26, 2023

On September 15, 2022, the World Professional Association for Transgender Health (WPATH), updated the Standards of Care for the Health of Transsexual, Transgender, and Gender Diverse People to Version 8. The updated recommendation from the WPATH no longer suggests two letters be required to recommend Gender-Affirming Medical and Surgical Treatment (GAMST) but rather one letter from an appropriate medical/mental health provider and/or multidisciplinary team involved in an individual’s treatment.     

Chapter II, Section 90.05-1(A)(4)(i) of the MaineCare Benefits Manual requires that the member has letters from two qualified Maine licensed health professionals who have independently assessed the member and are referring the member for surgery. The letters must establish that the member has gender dysphoria, has no other significant medical or mental health condition that would be contraindicated to surgery, and that the surgery is medically necessary for the member. Until such a time as Section 90.05-1(A)(4)(i) can be updated, the Department will review PA requests consistent with the updated recommendations found in Version 8 of the WPATH.    

If you have questions regarding coverage of services related to gender dysphoria or the PA guidelines, please contact your Provider Relations Specialist.