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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for any or all of the following requested facial feminization surgeries (21175 - reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (e.g., plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts); 21139 - reduction forehead, contouring and setback of anterior frontal sinus wall; 30420 - rhinoplasty, primary, including major septal repair; 20902 - bone graft, any donor area; major or large 61782 - stereotactic computer-assisted (navigational) procedure, cranial, extradural (list separately in addition to code for primary procedure); 21025 - excision of bone (e.g., for osteomyelitis or bone abscess), mandible; 21122  genioplasty, sliding osteotomies, two or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin); 15733 - muscle, myocutaneous, or fasciocutaneous flap, head and neck with named vascular pedicle (i.e., buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae); 15769 - grafting of autologous soft tissue, other, harvested by direct excision (e.g., fat, dermis, fascia); 15773 - grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet, 25 cc or less injectate; 67900 - repair of brow ptosis (supraciliary, mid-forehead or coronal approach); 14060 - adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 square cm or less.Authors reported, Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. facial feminization surgery, gender reassignment surgery, or both) are associated with improved mental health-related quality of life. The World Professional Association for Transgender Health (WPATH) position statement notes, Non-genital surgical procedures are routinely performed notably, subcutaneous mastectomy in female-to-male transsexuals, and facial feminization surgery, and/or breast augmentation in male-to-female transsexuals. These surgical interventions are often of greater practical significance in the patients daily life than reconstruction of the genitals. The WPATH position statement also states, The medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. The Health Plans claim that the patients individual facial features fall within a normal range for a female does not address the masculine impression of the facial features in relation to one another, nor the resulting dysphoria the patient experiences. The medical evidence supports the requested surgeries in this clinical setting. Therefore, all of the following requested facial feminization surgeries are medically necessary for the treatment of this patient: 21175 - reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (e.g., plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts); 21139 - reduction forehead, contouring and setback of anterior frontal sinus wall; 30420 - rhinoplasty, primary, including major septal repair; 20902 - bone graft, any donor area; major or large 61782 ; 21025 - excision of bone , mandible; 21122  genioplasty, sliding osteotomies, two or more osteotomies; 15733 - muscle, myocutaneous, or fasciocutaneous flap, head and neck with named vascular pedicle; 15769 - grafting of autologous soft tissue, other, harvested by direct; 15773 - grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet, 25 cc or less injectate; 67900 - repair of brow ptosis (supraciliary, mid-forehead or coronal approach); 14060 - adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 square cm or less. Final Result: The reviewer determined that all of the requested surgeries 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 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