Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender Dysphoria
Treatment: Facial Feminization Surgery
The insurer denied: Facial Feminization Surgery
The denial is overturned. 

The patient is an adult male to female transgender. The patient began hormone therapy 5 years ago. She has been living as a female and has undergone vaginoplasty. She has anxiety related to her male facial appearance. This is\ worsening her gender dysphoria. Her mental health professional and primary care physician (PCP) support the need for facial feminization surgery.

The requested facial feminization surgery is medically necessary.

According to the World Professional Association for Transgender Health (WPATH) (1): "5.5- We recommend transgender and gender diverse adults who fulfill the criteria for gender-affirming medical and surgical treatment require a single opinion for the initiation of this treatment from a professional who has competencies in the assessment of transgender and gender diverse people wishing gender-related medical and surgical treatment." According to the relevant surgical sections of the World Professional Association for Transgender Health guidelines (1): "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 that includes mental health and medical professionals that has 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 the patient has been stable on their current treatment regimen (which may include at least six 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). The patient has lived as a female and has been on hormone therapy for 5 years. This patient has anxiety, depression, and dysphoria that her mental health providers attribute directly to the incongruence of her facial
appearance with her assigned sex. A study found improved mental health functioning for transgender women following facial feminization surgery (2). The patient's condition represents a unique clinical situation in which facial feminization is indicated. A systematic literature review on facial feminization concluded (3): "based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients." A prospective, international, multicenter, cohort study concluded (4): "Facial feminization achieved improved quality of life, feminized cephalometries, feminine gender appearance, good overall aesthetics, and high satisfaction that were present at 1 month and stable at more than 6 months."
A recent study concluded (5): "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 as documented in the notes and letters from her treating mental health providers.
Therefore, the requested health service is medically necessary.