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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for facial feminization surgeries (CPT code 30420 (rhinoplasty, primary); CPT code 14041 (adjacent tissue transfer); CPT code 21209 (osteoplasty); CPT code 21139 (reduction forehead); CPT code 40799 (lip surgery procedure); CPT code 21122 (genioplasty, sliding osteotomy, two or more). Findings:  The physician reviewer found that a portion of the requested services is medically necessary and reconstructive in nature. Specially, CPT code 21139 (reduction forehead) and CPT code 14041 (adjacent tissue transfer) are medically necessary for the treatment of this patients gender dysphoria and is reconstructive in nature. The medical literature supports that facial feminization surgery can help to approximate a feminine appearance. Thus, there can be indications for surgical treatment to approximate a more normal female appearance. However, this should be considered on a case by case basis. In this patients case, the reduction of her forehead, CPT code 21139 (reduction forehead) and CPT code 14041 (adjacent tissue transfer) are medically necessary but the other requested services are not. The photographs support evidence of a masculine appearing forehead and anterior hairline. The nose, chin, upper lip and lower face are consistent with the female gender and/or are relatively gender neutral. However, the forehead and anterior hairline are more consistent with the male gender as supported by the documentation and the photographs. The patients nose, chin, upper lip and lower face are consistent within the spectrum of the female gender. For this patient, there has been sufficient justification for a portion of the requested services. Specifically, CPT code 21139 (reduction forehead) and CPT code 14041 (adjacent tissue transfer) are medically necessary for the treatment of the patients gender dysphoria. However, CPT code 30420 (rhinoplasty, primary); CPT code 21209 (osteoplasty); CPT code 40799 (lip surgery procedure); and CPT code 21122 (genioplasty, sliding osteotomy, two or more) are not medically necessary. With regard to whether the requested services are considered reconstructive in nature, the submitted documentation demonstrates that a portion of the patients condition constitutes an abnormal body structure. The records support that this patients forehead and anterior hairline constitute an abnormal body structure for a female gender. The reduction of the forehead and the adjacent tissue transfer would be reconstructive in nature. Additionally, the requested CPT code 21139 (reduction forehead) and CPT code 14041 (adjacent tissue transfer) would provide a more than a minimal improvement to the best extent possible. The requested CPT code 21139 (reduction forehead) and CPT code 14041 (adjacent tissue transfer) would approximate a more normal female appearance and would provide more than a minimal improvement of this patients forehead and hairline. However, the patients facial presentation as to CPT code 30420 (rhinoplasty, primary); CPT code 21209 (osteoplasty); CPT code 40799 (lip surgery procedure); and CPT code 21122 (genioplasty, sliding osteotomy, two or more) are not reconstructive in nature.  These requested services are more consistent with aesthetic improvement and are not specific to gender related abnormalities. For these reasons, CPT code 21139 (reduction forehead) and CPT code 14041 (adjacent tissue transfer) are reconstructive in nature. However, CPT code 30420 (rhinoplasty, primary); CPT code 21209 (osteoplasty); CPT code 40799 (lip surgery procedure); and CPT code 21122 (genioplasty, sliding osteotomy, two or more) are not reconstructive in nature. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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.