Appeal type: Medical necessity
Decision: Overturned

Dx: Gender Dysphoria
Tx: Pharmacy/Prescription Drugs
Denied: Lupron
Denial: OVERTURNED in whole

The patient was assigned to the female gender at birth and was subsequently diagnosed with gender dysphoria. The patient began to have feelings of dysphoria around the start of puberty approximately 4 years ago, and the dysphoria has progressively become worse. The patient came out as transgender  and has attended school since the fall of last year. The patient has been evaluated and followed by a mental health team with extensive experience in the field of transgender medicine and was diagnosed with gender dysphoria (GD). The patient presented to a pediatric endocrinologist, to discuss pubertal suppression and suppression of menses. Leuprolide (GnRH) therapy was recommended as per the Endocrine Society Guidelines for endocrine treatment of gender dysphoric/gender incongruent persons, as well as per the guidelines issues by the World Professional Association for Transgender Health (WPATH). More specifically, the Endocrine Society guidelines state that "adolescents who meet diagnostic criteria for GD/gender incongruence, fulfill criteria for treatment, and are requesting treatment should initially undergo treatment to suppress pubertal development." Despite these guidelines, treatment was denied by the health plan.

The health plan's determination is overturned in whole.

The medication is medically necessary in order to suppress puberty in a transgender patient, as per the Endocrine Society Guidelines. Denying this treatment will be detrimental to the patient and is against the standard of care.
This patient is progressing through puberty and has reached menarche. Changes associated with the body habitus and monthly menses can be incredibly distressing to a transgender individual, which has been the case with this patient, and can lead to worsening depression and suicidal ideation. Unfortunately, there are not many other feasible options to suppress menses. Oral contraceptive pills can be utilized; however, the estrogen component can cause further feminization, which can be quite psychologically distressing. Progesterone therapy does not completely suppress menses and has multiple unfavorable side effects. Gonadotropin-releasing hormone (GnRH) therapy such as leuprolide does not only suppress menstrual periods but will also halt further feminizing changes such as further breast development and female hip/waist body habitus which are irreversible and can be incredibly distressing to a transgender person. To address the point of the denial which states that Lupron must be used concomitantly with cross sex hormones, such as testosterone in this patient's case, this is not the standard of care. The Endocrine Society guidelines specifically state "In adolescents who request sex hormone treatment (given this is partly irreversible treatment), we recommend initiating treatment using a gradually increasing dose schedule after a multidisciplinary team of medical and mental health professionals (MHPs) has confirmed the persistence of GD/gender incongruence and sufficient mental capacity to give informed consent, which most adolescents have by age 16 years." The first step is typically to suppress puberty using a GnRH analogue such as leuprolide, followed by close monitoring by a mental health professional and pediatric endocrinologist, until an age when the patient fully understands the risks and benefits of testosterone therapy. When testosterone therapy is initiated, GnRH therapy can be discontinued and using the two concomitantly is not typically done. At this point one must follow the guidelines to offer the patient GnRH therapy to suppress puberty and denying the patient Lupron therapy will cause further psychological distress and depression. Suggesting that gender-affirming therapy is initiated at this time in conjunction with Lupron at this young age goes against the guidelines and standard of care.