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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgeries including reduction forehead, contouring and setback of anterior frontal (21139); brow lift (67900); genioplasty, sliding osteotomy (21121), osteotomy, mandible, segmental (21198); osteoplasty, facial bones, augmentation, reduction (21209); rhinoplasty, including major septal repair (30420); punch graft for hair transplant: 1-15 punches (15775); punch graft for hair transplant: more than 15 punches (15776); and graft, composite (e.g. full thickness of external ear or nasal ala), including primary closure, donor area derma-fat-fascia (15770). This patient identifies as female and has been living in a gender role consistent with her affirmed gender. Findings:  The physician reviewer found that the  patient started hormone therapy and underwent tracheal shave surgery as well as recent reconstruction of genitalia. The patients providers have recommended facial feminization surgery to continue the patients transition to female. Per the World Professional Association for Transgender Health (WPATH), facial feminization surgery is appropriate for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The WPATH supports facial feminization surgery to help alleviate the distress associated with an incongruent physical appearance and gender identity. WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. The guidelines further report that, these reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved patients mental health-related quality of life. gender dysphoria. Given these findings, the requested facial feminization surgeries including reduction forehead, contouring and setback of anterior frontal (21139); brow lift (67900); genioplasty, sliding osteotomy (21121), osteotomy, mandible, segmental (21198); osteoplasty, facial bones, augmentation, reduction (21209); rhinoplasty, including major septal repair (30420); punch graft for hair transplant: 1-15 punches (15775); punch graft for hair transplant: more than 15 punches (15776); and graft, composite (e.g. full thickness of external ear or nasal ala), including primary closure, donor area derma-fat-fascia (15770) are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are 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 with expertise in transgender health 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.