Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the facial feminization surgery performed. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee's gender dysphoria. At issue in this case is whether the facial feminization surgery was medically necessary for treatment of the patients gender dysphoria. The guidelines for the medical necessity of FFS exist in two reviews from World Professional Association for Transgender Health (WPATH) and the Transgender Law Center. On the matter of medical necessity and the classification of FFS as reconstructive surgery, WPATH states that: In addition to hormonal balancing, medically necessary gender affirming/confirming surgical procedures are described in section XI of the standard of care (SOC). These procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient, including for example skin flap hair removal; scrotoplasty; and penile and testicular prostheses, as necessary; facial hair removal; certain facial plastic reconstruction; voice therapy and/or surgery; and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. The medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. The Transgender Medicine Model NCD Working Group, Transgender Law Center, in their review of evidence for FFS state that: Other surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women includereconstructive facial feminization surgeryThese procedures are not cosmetic, but rather serve a primarily reconstructive purpose by allowing transgender women whose overall physical appearance otherwise prevents them from being perceived as female.Facial feminization surgery (FFS) would provide reconstructive surgical services for an abnormality because of the disorder of gender dysphoria. The outcome of reconstructive surgery would be enhancement of psychological and social functioning. The patient has a documented history of gender dysphoria. Based on the documented history of gender dysphoria and evidence of the medical necessity of FFS, the requested facial feminization surgery was medically necessary. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.