Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria

Treatment: Facial and Neck Gender affirming surgery procedures

The insurer denied coverage for Facial and Neck Gender affirming surgery procedures.

The denial is overturned.
 

Facial feminization is a standard treatment for gender dysphoria and is medically necessary for this patient.

According to the relevant surgical sections of World Professional Association of Transgender Health (WPATH) guidelines, 8th edition:

13.6- We suggest health care professionals consider gender-affirming genital procedures for eligible* transgender and gender diverse adults seeking these interventions when there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).
13.7- We recommend surgeons consider gender-affirming surgical interventions for eligible* transgender and gender diverse adolescents when there is evidence a multidisciplinary approach that includes mental health and medical professionals has been involved in the decision-making process.

In this case, there is evidence of a multidisciplinary approach that includes mental health and medical professionals involved in the decision-making process.  The patient's therapists and surgeon recommend facial feminization surgery as a key component of treatment for gender dysphoria. In addition, there is evidence this patient has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).  The patient has lived as a female and has been on hormone therapy. This patient has anxiety, depression and dysphoria that her mental health providers attribute directly to the incongruence of her facial appearance with her assigned sex. According to the letter from the patient's therapist: "Specifically, the patient's hair line, brow ridge, nose, jawline, cricothyroid cartilage and chin create a masculine appearance to her face that cannot be addressed by feminizing hormone therapy alone. These boney features of her face cause dysphoric symptoms both when seeing her own face in the mirror and when being seen by others. She often does not leave the house because of these symptoms and to avoid subjecting herself to the social stigma of being transgender. This patient has no medical or behavioral health issues that contradict gender-affirming surgery." A study by Ainsworth et al found improved mental health functioning for transgender women following facial feminization surgery. Her condition represents a unique clinical situation in which facial feminization is indicated.  A systematic literature review on facial feminization by Morrison et al concluded: "based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients.". Her condition represents a unique clinical situation in which facial feminization is indicated.  A prospective, international, multicenter, cohort study by Morrison et al concluded: "Facial feminization achieved improved quality of life, feminized cephalometries, feminine gender appearance, good overall aesthetics, and high satisfaction that were present at 1 month and stable at more than 6 months."  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Facial and Neck Gender affirming surgery procedures is substantiated.