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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for body feminization surgery (CPT codes 15877 suction assisted lipectomy of the trunk (abdomen and flanks); 15879 suction assisted lipectomy of the lower extremities (outer/inner thighs) and 20929, tissue grafts, other (paratenon, fat, dermis)) for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that based on the entirety of the medical documentation provided for review, including review of the photographs, the requested services are not medically necessary in this clinical setting. Although this patient has documented gender dysphoria, the submitted photographs appear to support a normal appearance for a female. The photographs provided show evidence of a mildly obese abdomen that extends to the flanks, with a small overhanging lower abdominal pannus. The patients abdomen is not identified as a male contour, but appears to be more related to her weight and skeletal structure. In addition, the photographs of the upper thighs appear to be relatively normal. These findings are relatively gender neutral. Therefore, this patients body structure is not atypical for a female appearance. This patients appearance can be consistent in the spectrum of possible typical female appearances. Overall, the clinical documentation is insufficient to support the requested services. In sum, the body feminization surgery (CPT codes 15877 suction assisted lipectomy of the trunk (abdomen and flanks); 15879 suction assisted lipectomy of the lower extremities (outer/inner thighs) and 20929, tissue grafts, other (paratenon, fat, dermis) is not medically necessary for treatment of this patients medical condition. With regards to whether the requested services are reconstructive in nature, the patient has a relatively normal appearance that is not necessarily gender specific. As stated and reasoned above, the requests appear consistent with aesthetic improvement, addressing appearance concerns and not specific gender related abnormalities. There is a wide spectrum of abdominal and lower extremity appearances that can be consistent with possible/typical female appearances. Thus, this patients presentation should not be considered an abnormal structure for the abdomen or thighs and the requested services are not expected to provide a more than minimal improvement in the patients appearance. For these reasons, body feminization surgery (CPT codes 15877 suction assisted lipectomy of the trunk (abdomen and flanks); 15879 suction assisted lipectomy of the lower extremities (outer/inner thighs) and 20929, tissue grafts, other (paratenon, fat, dermis) is not reconstructive in nature.  Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.