Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Gender Dysphoria
Treatment: Surgery (Codes: 21137, 21256, 15876, 21296, 21209, 31081)
The insurer denied the Surgery (Codes: 21137, 21256, 15876, 21296, 21209, 31081)
The denial is overturned, in part. 

The patient is a trans-woman. She transitioned socially many years ago. She started hormones several years ago.  She has intractable dysphoria on a daily basis due to her masculine features. She has tried various conservative measures to improve her masculine appearance, including makeup and hairstyle.  Despite these interventions, she continues to have significant dysphoria. She has already been treated with vaginoplasty and breast augmentation. Facial feminization is recommended.

Yes, in part. The proposed treatment is medically necessary, in part. Specifically, codes 21296 and 21137 are medically necessary, while codes 21256, 15876, 21209, and 31081 are not medically necessary.
The codes in question are as follows: 21137, 21256, 15876, 21296, 21209, and 31081. The code descriptions are as follows:

-21137: Brow reduction
-21256: Orbit reconstruction
-31081: Obliteration of frontal sinus
-15876: Suction lipectomy
-21296: Reduction master
-21209: Reduction facial bones.

Code 21256 (Orbit reconstruction) is not medically necessary. Transgender patients benefit from brow reduction. This procedure does not generally involve orbit reconstruction. The patient does not require orbit reconstruction to have more feminine appearance.

Code 31081 (Obliteration of frontal sinus) is not medically necessary. This is a component part of the brow reduction. The brow reduction cannot be performed unless frontal sinus mucosa is removed.

Code 15876 (Suction lipectomy) is not medically necessary. Suction lipectomy is cosmetic.

Code 21209 (Reduction facial bones) is not medically necessary. Reduction of the masseter muscle and bone is covered with code 21296. Code 21209 is redundant.

Codes 21137 (Brow reduction) and 21296 (Reduction master) are medically necessary to treat the patient's gender dysphoria and render her appearance more feminine. According to the World Professional Association for Transgender Health (WPATH) guidelines, "Other surgeries for assisting in body feminization include reduction thyroid chondroplasty (reduction of the Adam's apple), voice modification surgery, suction-assisted lipoplasty (contour modeling) of the waist, rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid). Other surgeries for assisting in body masculinization include liposuction, lipofilling, and pectoral implants. Voice surgery to obtain a deeper voice is rare but may be recommended in some cases, such as when hormone therapy has been ineffective.

"Although these surgeries do not require referral by mental health professionals, such professionals can play an important role in assisting clients in making a fully informed decision about the timing and implications of such procedures in the context of the social transition."

"Although most of these procedures are generally labeled 'purely aesthetic,' these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient's condition and life situation. This ambiguity reflects reality in clinical situations and allows for individual decisions as to the need and desirability of these procedures."

This patient has anxiety that her mental health providers attribute directly to her facial gender incongruity. She has significant dysphoria that her physician believe is secondary to the incongruence of her facial appearance with her assigned sex.

A study by Ainsworth, et al found improved mental health functioning for transgender women following facial feminization surgery. The patient's condition represents a unique clinical situation in which facial feminization is indicated.

A systematic literature review on facial feminization by Morrison, et al concluded, "Based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients."

This patient has dysphoria and social isolation that her mental health providers attribute directly to her facial gender incongruity. She has significant dysphoria that her physician believe is secondary to the incongruence of her facial appearance with her assigned sex.  These procedures are necessary to treat the patient's unique clinical situation of disabling dysphoria related to the incongruence of her facial appearance.

Specifically, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient for codes 21296 and 21137. However, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient for codes 21256, 15876,  21209, and 31081.

Codes 21137 and 21296 are medically necessary to treat the patient's gender dysphoria and render her appearance more feminine.  The other codes are cosmetic.