Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Male to Female Gender Transition. 
Treatment: Thyroid cartilage reduction for feminization, procedure code 31899-SG. 
The insurer denied coverage for thyroid cartilage reduction for feminization, procedure code 31899-SG. 
The denial is upheld. 

This male to female transgender patient underwent thyroid cartilage reduction for feminization. Medical necessity using standard of care guidelines is not met. According to the World Professional Association for Transgender Health (WPATH) 8th Edition:

The following recommendations are made regarding the requirements for gender-affirming medical and surgical treatment (all should be met): 

5.3- We recommend health care professionals assessing transgender and gender diverse adults for gender-affirming medical and surgical treatment: 
5.3A- only recommend gender-affirming medical treatment requested by a transgender person when the experience of gender incongruence is marked and sustained. 
5.3B- ensure fulfillment of diagnostic criteria prior to initiating gender-affirming treatments in regions where a diagnosis is necessary to access health care. 
5.3C- Identify and exclude other possible causes of apparent gender incongruence prior to the initiation of gender-affirming treatments. 
5.3D- ensure that any mental health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed, before a decision is made regarding treatment. 
5.3E- ensure any physical health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed, before a decision is made regarding treatment. 
5.3F- assess the capacity to consent for the specific physical treatment prior to the initiation of this treatment. 
5.3G- assess the capacity of the gender diverse and transgender adult to understand the effect of gender-affirming treatment on reproduction and explore reproductive options with the individual prior to the initiation of gender-affirming treatment. 
5.5- We recommend transgender and gender diverse adults who fulfill the criteria for gender-affirming medical and surgical treatment require a single opinion for the initiation of this treatment from a professional who has competencies in the assessment of transgender and gender diverse people wishing gender-related medical and surgical treatment. 

These guidelines are not met. The records do not include documentation of a preoperative evaluation by a mental health professional that confirms that the following guidelines are met: 5.3 and 5.5. Of note is that 5.5 states: "We recommend transgender and gender diverse adults who fulfill the criteria for gender-affirming medical and surgical treatment require a single opinion for the initiation of this treatment from a professional who has competencies in the assessment of transgender and gender diverse people wishing gender-related medical and surgical treatment." In this case, the records do not include a letter or consult note from a mental health professional with expertise in the treatment of transgender individuals that confirms that the requested surgery is appropriate for this individual. 

The procedure is not medically necessary because the records do not include documentation of a comprehensive mental health evaluation prior to surgery by a therapist specializing in transgender care. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for procedure code 31899-SG is not substantiated.