Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender Dysphoria, Excess Skin.
Treatment: Body Contouring Procedures.
The insurer denied the Body Contouring Procedures as not medically necessary.
The determination is upheld.

This case involves a transgender patient who has lost 100 pounds. The patient has excess skin that is physically and mentally painful. Photos show generalized skin excess. Body contouring surgery is recommended. The patient reports rashes and that clothing that does not fit properly. At issue is whether the requested procedures are medically necessary.
These procedures are not medically necessary. The patient has generalized skin laxity consistent with the history of massive weight loss. Correction of skin laxity following massive weight loss is generally considered not medically necessary in the absence of clear and compelling documentation of specific signs and symptoms that 1) are clearly related to the excess skin 2) are health threatening or cause significant disability and 3) have failed to improve despite reasonable attempts at conservative therapy. A reasonable standard for evaluating the medical necessity of the surgery is whether the submitted records include convincing and confirmatory evidence of a chronic health condition that has failed reasonable attempts at conservative therapy. These proposed procedures do not meet this standard. The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin fold, and photographs documenting cellulitis, ulcerations or rashes are not submitted. In addition, the medical records do not provide any documentation in the form of primary care physician (or provider) (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to topical therapy given or 2) despite initial response, have recurred and caused significant impairment. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and member appeal testimonies in the absence of physician office note of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.
These procedures are not required as part of gender dysphoria treatment. According to the World Professional Association for Transgender Health (WPATH) guidelines, pages 63-64: "Other surgeries for assisting in body feminization include reduction thyroid chondroplasty (reduction of the Adam's apple), voice modification surgery, suction-assisted lipoplasty (contour modeling) of the waist, rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid). Other surgeries for assisting in body masculinization include liposuction, lipo-filling, and pectoral implants. Voice surgery to obtain a deeper voice is rare but may be recommended in some cases, such as when hormone therapy has been ineffective. Although these surgeries do not require referral by mental health professionals, such professionals can play an important role in assisting clients in making a fully informed decision about the timing and implications of such procedures in the context of the social transition. Although most of these procedures are generally labeled 'purely aesthetic,' these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient's condition and life situation. This ambiguity reflects reality in clinical situations, and allows for individual decisions as to the need and desirability of these procedures." The records do not document any unique situations. The requested procedures are not medically necessary.