Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria.
Treatment: Facial Feminization Surgery (21139, 21180, 21270, 15824, 30410, 15774, 15773, 21296, 21209).
The insurer denied: Facial Feminization Surgery (21139, 21180, 
21270, 15824, 30410, 15774, 15773, 21296, 21209).
The denial is overturned.

The patient is an adult transfeminine person. The request is for facial feminization surgery to treat her gender dysphoria. Her mental health professionals confirm that she has symptoms consistent with the DSM-V (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) guidelines for Gender Dysphoria (ICD10 [International Classification of Diseases] Code F64.0). She has persistent and consistent identity as a transfeminine person. She has known herself to feel discomfort in her body since puberty, and this feeling persisted throughout adulthood. She has lived as her gender since several years ago, and has affirmed this identity through social transition, a legal name change, gender-affirming hormone care, and other gender affirming surgeries. She is now seeking facial feminization surgery, including but not limited to frontal bone osteotomy, orbital bone reconstruction, coronal brow lift, rhinoplasty, cheek implants, mandible angle reduction, masseter resection, and facial fat grafting, to feel more complete in her sense of self. The patient has directly discussed the dysphoria she experiences from her facial shape and structure. As a result of this dysphoria. She reports profound anxious and depressed moods which have affected her personal and professional life. 

The requested Facial Feminization Surgery is medically necessary.

According to the relevant surgical sections of WPATH (World Professional Association for Transgender Health) guidelines, 8th edition (12): "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, including mental health and medical professionals that 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 that the 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).  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."
A recent study by Chou et al concluded: "FFS [facial feminization surgery] improves self-perceived and externally perceived facial femininity and reduces limitations in social and professional 
activities."

These procedures are necessary to treat the patient's unique clinical situation of disabling dysphoria related to the incongruence of her facial appearance.