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

Standard Review:A transgender female enrollee has requested authorization and coverage for hair transplant surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for treatment of the enrollees gender dysphoria.  Credentials/Qualifications: The reviewer is board certified in plastic surgery 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. Nature of Statutory Criteria/Case Summary: Based on the entirety of the medical documentation provided for this review including a review of the photographs, hair transplantation for this patient is not medically necessary at this time.  Surgical treatment to establish a female appearance should be considered on a case by case basis. In the documentation provided, there has not been sufficient documentation that a typical functional deficit is present that requires surgical treatment. According to the documentation and the photographs provided, this patient has a relatively normal appearance for a female with respect to the hairline.  Although the patient has an anterior hairline and mild temporal recession, this would not be considered strictly a male appearance.  Olsen noted in an article regarding female pattern hair loss, Until recently, the patterns of hair loss in affected women generally have been considered to be either of 2 patterns: male pattern baldness (although more limited in scope and degree) or progressive loss of hair density in a uniform pattern over the top of the scalp with preservation of the frontal margin. Accordingly, the patients current hair pattern can be considered a normal occurrence in females.  Moreover, the degree of severity as seen in the photographs should be considered relatively mild.  Finally, the patient is undergoing a change in her hairline with the approved procedure of scalp advancement.  As stated by the treating provider, transplantation should not be performed at the same time of the scalp advancement.  Once the results from the scalp advancement can be evaluated, then other secondary procedures could be considered including hair transplantation.  In this patients case, her current hair pattern can be seen in both females and males. It is not beyond what can be seen typically in females. Therefore, the requested hair transplant surgery is not medically necessary for treatment of this patients medical condition. With regard to whether the patients hairline constitutes an abnormal structure of the body, based on the entirety of the medical documentation and review of the photographs, this patients hairline is not an abnormal structure of the body. She has an appearance that can be considered within a normal spectrum of female appearances. In addition, the hairline will be modified with the approved scalp advancement and would not be prudent to perform hair transplantation at the same time. As such, this patients hairline presentation should not be considered an abnormal structure. In sum, the requested hair transplant surgery is not reconstructive in nature for treatment of this patients gender dysphoria. Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.