Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria.
Treatment: Revision of Facial Feminization Surgery.
The insurer denied: Revision of Facial Feminization Surgery.
The denial is overturned.

This is an adult male-to-female transgender patient. They identify as female. They have been consistently on hormone therapy since the middle of the 1990's. Despite these interventions, they report significant anxiety, depression, and distress due to their experience of dysphoria. They have expressed a persistent desire for facial feminization surgery.

According to the therapist, the patient has begun to experience a significant and impairing degree of gender dysphoria about her facial features as she ages and as the fat distribution in her body changes. Specifically, now she needs multiple facial feminization procedures including but not limited to brow lift, facelift, fat graft, and work on her forehead, eyelids, and lips. She has researched the procedures and she is knowledgeable about issues related to FFS (facial feminization surgery), including risks, permanence, and recovery. She is aware that the recovery can be lengthy.

The patient lives next door to her sister and her mother, who will help in her recovery. The patient owns her own home and has financial savings to support herself during recovery, as well. Facial feminization surgery is planned.

The requested health service is medically necessary.

According to the relevant surgical sections of WPATH (World Professional Association for Transgender Health) 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 have been 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 the individual has been stable on their current treatment regime (which may include at least six 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 for years and has been on hormone therapy since the middle of the 90s. 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.

A study by Ainsworth et al found improved mental health functioning for transgender women following facial feminization surgery. The patient's 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."

All of the WPATH (World Professional Association for Transgender Health) guidelines for facial feminization are met.