Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria.

Treatment: Facial feminization surgery for male to female transition, codes 15819 Cervicoplasty, 15824 Rhytidectomy; fore, 21139 Reduction forehead; contouring and setback of anterior frontal sinus wall, 30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip, 31599 Unlisted procedure, larynx and 40799 Unlisted procedure, lips for treatment of gender dysphoria.

The insurer denied coverage for facial feminization surgery for male to female transition, codes 15819 Cervicoplasty, 15824 Rhytidectomy; fore, 21139 Reduction forehead; contouring and setback of anterior frontal sinus wall, 30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip, 31599 Unlisted procedure, larynx and 40799 Unlisted procedure, lips for treatment of gender dysphoria.

The denial is overturned.

This is a transgender female patient who had a diagnosis of gender dysphoria. She was requesting facial surgery as a next step to transition. She was receiving hormone therapy and was socially transitioning as a female. She desired multiple times to appear more feminine and reported that she was distressed and was functionally handicapped and struggling by other's perception regarding her feminine self. 

According to the American Family Physician 2013 January 15:87 (2); 89-93 the World Professional Association Transgender Health (WPATH) is an international multidisciplinary professional association publishing standards for the care of transgender and gender variant persons. According to WPATH, gender affirming surgery is accepted medical practice for the treatment of gender dysphoria and is recognized as an effective treatment of gender dysphoria with a triadic approach. 

This patient had reports of being distressed and was functionally handicapped and struggling by other's perception regarding her feminine self. She reportedly had depression and anxiety and was taking psychotropic medications. Facial feminization surgery was not considered cosmetic but medical necessary to decrease distress and mental health issues and improve functioning and to feel more comfortable as a female as well as taking the next step to transition to a female. With her masculine facial features, she reportedly did not feel comfortable in her gender identity. This patient reportedly had hormone therapy for more than 1 year and she also was living as a female and socializing as a female for more than 1 year of living in the female role full time which also is a reported requirement prior to surgery. 

This reviewer disagrees with the insurer's decision to deny coverage for facial feminization surgery including cervicoplasty, rhytidectomy, forehead reduction, contour, and setback, anterior frontal sinus wall, rhinoplpasty, elevation of the nasal flip, and also lip and larynx surgery as this was not considered cosmetic surgery but rather medically necessary surgery for this patient to transition better into the female gender and with the current emotional discomfort due to feeling like a woman in a man's skull and face, it was causing distress.

It did not appear that the health care plan acted reasonably or in the best interests of the patient.  

The insurer's denial of coverage for facial feminization surgery for male to female transition, codes 15819 Cervicoplasty, 15824 Rhytidectomy; fore, 21139 Reduction forehead; contouring and setback of anterior frontal sinus wall, 30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip, 31599 Unlisted procedure, larynx and 40799 Unlisted procedure, lips for treatment of gender dysphoria is overturned. Medical necessity is substantiated.