Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Gender dysphoria.
Treatment:  Chin surgery (procedure code 21122) (genioplasty).

The insurer denied coverage for chin surgery (procedure code 21122) (genioplasty).  The denial is overturned.  

This transgender patient was diagnosed with persistent and severe gender dysphoria. She has had psychological and hormonal treatment, and underwent gender affirming vaginoplasty and gender affirming breast augmentation. An Oral and Maxillofacial Surgery Specialist recommended genioplasty or chin surgery to address the patient's masculine facial appearance and to treat the diagnosis of persistent and severe gender dysphoria. 

According to the World Professional Association for Transgender Health (WPATH) guidelines, pages 63-64: "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." 

Based on the records provided for review this patient has, a "unique clinical situation" warranting facial chin surgery. Per the records: "Her male facial characteristics including square angulated features and broad mandible bone structure provoke her persistent and severe gender dysphoria and interfere with her ability to integrate socially into the community as a woman; her masculine facial appearance impairs her ability to perform activities of daily life, she previously left a teaching position due to her masculine appearance and she currently struggles to perform her work duties due the nature of online teaching which requires sustained interactions with her face prominently visible."  The records from several health professionals document that this patient has significant issues that are attributable to her male facial appearance. Per the WPATH guidelines, facial feminization chin surgery is medically necessary due to her unique clinical circumstances.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity is substantiated. The carrier's denial of coverage for the chin surgery (procedure code 21122) (genioplasty) is overturned.