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

Standard Review The parent of a transgender female enrollee has requested reimbursement for gender reassignment surgery performed in 2017. The Health Plan has denied this request indicating that the services at issue were not medically necessary and were not reconstructive in nature for treatment of the enrollees gender dysphoria. Credentials/Qualifications: The reviewer is board certified in plastic surgery 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. Nature of Statutory Criteria/Case Summary: The documentation provided supports the services at issue in this clinical setting. Based on the documentation provided, the patient has gender identity disorder and had been in transition for over one year. The patient is a transgender female who is well-documented to have gender dysphoria and had undergone gender reassignment surgery.  Prior to her surgery, she was treated appropriately with hormonal therapy and living as a female. Her surgical transition was supported by multiple providers and mental health professionals. The American Society of Plastic Surgeons recommends an evaluation of the physical and emotional maturity as well as seeking the guidance of a certified plastic surgeon. The literature notes that the most rewarding outcomes are expected when the following exist: the adolescent initiates the request, the teenager has realistic goals and the adolescent appreciates both the benefits and limitations of plastic surgery, avoiding unrealistic expectations about life changes that will occur as a result of the procedure. Adolescents must be able to tolerate the discomfort and temporary disfigurement of a surgical procedure. Plastic surgery is not recommended for adolescents who are prone to mood swings or erratic behavior, who are abusing drugs and/or alcohol, or who are being treated for clinical depression or other mental illness.  Based on the documentation provided, including the supporting letters from physicians and mental health professionals, this patient has met the above mentioned guidelines.  The records note that she has had a real-life experience in the desired role and has undergone hormone therapy. The gender reassignment surgery was part of the surgical transition process. The patient was well documented to have gender dysphoria prior to the surgery. As such, her external anatomy should be more consistent with a female than a male. While the Health Plan criteria indicates that the patient should have been 18 prior to undergoing surgical intervention, pubertal development is as important as chronological age. Each patient must be reviewed on a case-by-case basis to determine medical necessity.   In this patients case, medical necessity was adequately defined by the documentation despite her chronological age. Although this type of surgical intervention should be considered with great care in an adolescent or teenager, the documentation from multiple physicians, mental health professionals, and the parents support that the patient was a reasonable candidate for the gender reassignment surgery. Moreover, the surgery at issue is supported in peer-reviewed references as well. For these reasons, the gender reassignment surgery was medically necessary.With regard to whether the services at issue were reconstructive in nature, the submitted documentation reveals that the patients male anatomy was an abnormal structure for a female body. The abnormal structure was a result of the patients gender dysphoria which can be considered a congenital or developmental abnormality. The surgery was performed to improve function, as it was part of the patients surgical transition from the male to female gender. Further, the surgery helped to provide more than a minimal improvement in the female appearance of this patient. Therefore, the gender reassignment surgery was reconstructive in nature. Final Result: The reviewer determined that the services at issue were medically necessary and were reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.