Authorizations

SFHP Medical Criteria

These guidelines apply to Medi-Cal, Healthy Workers HMO, and Healthy Kids HMO.

UM Criteria for Non-Genital Gender Confirmation Services
Supporting documentation and forms:

• Medical Evaluation form
• Behavioral Health Evaluation form

Patient Education forms:

• Mammoplasty
• Mastectomy with Male Chest Reconstruction

UM Criteria for Genital Gender Confirmation Services
Supporting documentation and forms:

• Medical Evaluation form
• Behavioral Health Evaluation form

Patient Education forms:

• Hysterectomy
• Orchiectomy
• Vaginoplasty
• Metoidioplasty
• Phalloplasty/Penile Prosthesis

UM Criteria for EPSDT Private Duty Nursing