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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgeries (CPT codes 21179 - reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material, 14301 - adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm, 15824 - rhytidectomy, forehead, 30410 - rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip; 20926 - tissue grafts, other (e.g. paratenon, fat, dermis), and 21209 - osteoplasty, facial bones; reduction). This patient meets the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) criteria for gender dysphoria and indication for facial feminization surgery based upon clinical documentation of persistent gender dysphoria related to masculine facial features associated with agoraphobia. The WPATH SOC indicated that facial feminization surgery is supported as medically necessary for the treatment of gender dysphoria in some transgendered individuals. In terms of patient selection, the WPATH SOC noted that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The WPATH SOC recognizes additional surgeries to promote body feminization may include rhinoplastyfacial bone reduction, face-lift, and blepharoplasty. This patient has documented persistent gender dysphoria and social dysfunction, as noted by multiple providers. She has been in the process of medical and surgical transition for more than 1.5 years. Treatment has included feminizing hormone treatment since March and breast augmentation in April. The patient has a masculine facial structure from exposure to testosterone during puberty and adolescence. The patients psychologist, primary care provider, and health manager attest the patients gender dysphoria is exacerbated by the presence of these masculine facial features. The patients gender dysphoria includes symptoms of substantial distress, social anxiety, and agoraphobia. Her providers indicate that facial feminization surgery can lead to a reduction of the patients distress of gender dysphoria and improvement in quality of life. Given these findings, the requested facial feminization surgery is medically necessary to help alleviate the patients gender dysphoria and related distress. For these reasons, the facial feminization surgeries (CPT codes 21179 - reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material, 14301 - adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm, 15824 - rhytidectomy, forehead, 30410 - rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip; 20926 - tissue grafts, other (e.g. paratenon, fat, dermis), and 21209 - osteoplasty, facial bones; reduction) are medically necessary for treatment of this patients gender dysphoria. Final Result: The reviewer determined that the requested services 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 with expertise in transgender health 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.