Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gender dysphoria
Treatment:  Facial feminization procedure and revision vaginoplasty
Facial feminization and revision vaginoplasty are not medically necessary.
The patient is a male to female transgender woman.  The treating physician proposes facial feminization surgery and revision vaginoplasty for treatment of gender dysphoria.

Review of the medical literature regarding facial feminization procedures demonstrates that while some facial feminization procedures addressing secondary sex characteristics can be effective in bringing the patient's face into increased congruence with their gender identity, there is no specific objective minimum degree of feminization or absolute requirement requiring a minimum feminine appearance in regards to medical necessity regarding facial feminization.  Therefore, actual documentation of the patient's gender dysphoria specific to the patient's facial appearance, as well as the patient's clinical treatment to address and manage gender dysphoria, is required to assess the degree of severity.  Photographs can be helpful to correlate the patient's gender dysphoria associated with the patient's facial characteristics.

The patient's documentation from a care provider states she has "very masculine features".  Letters of affirmation from the patient's care providers also state the patient has continued gender dysphoria due to her masculine appearing hairline, forehead, brow and nose, resulting in gender incongruence.

However, the description of the patient's facial features is primarily descriptive and qualitative in nature.  There are no objective measurements regarding facial appearances, which can be correlated to the qualitative description.

Based on the clinical information reviewed, there is inadequate documentation regarding evidence of clinically significant distress in social, occupational, or other areas of functioning.  Broad and generalized letters of attestation are all provided as part of the documentation in regards to the appeal for facial feminization surgery; however, no actual clinical notes at the time when the patient experienced gender dysphoria secondary to facial appearance are provided. 

While the patient is reported to have experienced multiple clinically significant functional issues secondary to distress regarding gender dysphoria, no time-specific documentation is provided regarding the clinical assessment and management that was undertaken to address this condition related to the patient's facial features that would have reasonably led to the patient seeking facial feminization treatment.  No photographs were provided which may be helpful in correlating the descriptions regarding "masculine features". 

In addition, the only clinical description regarding the indication for revision vaginoplasty is a brief description of "significant scar tissue."  There is a qualitative description stating there are "thick bands of scar tissue" "causing discomfort and negatively effecting urination."  It is unclear whether a revision vaginoplasty is indicated or a different urologic procedure or other soft tissue scar revision procedure would be considered more appropriate or clinically effective.  Without appropriate clinical documentation outlining the specific nature of the condition to be treated, a revision vaginoplasty cannot be considered medically necessary.

Therefore, medical necessity has not been established for facial feminization surgery and revision vaginoplasty at this time.  The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.