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

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested authorization and coverage for breast augmentation for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that The documentation provided does not support the medical necessity for the requested services in this clinical setting. The medical necessity of breast augmentation for transgender females with gender dysphoria is a case specific determination. This patient has documented gender dysphoria and has been undergoing female transitioning with hormonal therapy for approximately four years. Based on her diagnosis and history, her external anatomy should be more consistent with the female gender. However, her examination detail and review of the photographs support that she has had sufficient breast development with hormone therapy. The records show that she has fully developed breast tissue with a Tanner breast stage of 5. Her examination detail notes underdeveloped breasts, but her breasts are consistent within the spectrum of female chest contour. Additionally, a review of the photographs support that she has sufficient breast development. The photographs show well-defined breast mounds and well-defined inframammary folds which are consistent with the female chest contour within the spectrum of typical female appearances. Therefore, based on the entirety of the documentation provided as well as the photographs, breast augmentation is not medically necessary for treatment of this patients gender dysphoria. With regard to the whether the requested services are considered reconstructive in nature, in this patients case, the requested breast augmentation is not reconstructive in nature. The medical literature supports breast augmentation in male to female patients as part of gender reassignment surgery. Hormonal feminization might not be sufficient to induce mammogenesis, so patients seek surgery to augment their chests to resemble the female gender. However, this patients external breast anatomy is consistent within the spectrum of the female gender breast anatomy. As such, her breast development is not an abnormal structure of the body for a female gender. In addition, there are no indications for functional improvement present. The requested surgery would not help to create a normal appearance to the extent possible and would not provide a minimal improvement in the appearance. This patients breast development is consistent with the female gender. Therefore, in this clinical setting, the requested breast augmentation would be performed to enhance relatively normal structures. For these reasons noted above, breast augmentation is not reconstructive in nature.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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.