Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria

Treatment: Facial feminization surgery (FFS)

The insurer denied coverage for (21139) - Reduction forehead; contouring and setback of anterior frontal sinus wall, (21267)- Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach, (15824) - Rhytidectomy; forehead,  (21122)- Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g. wedge excision or bone wedge reversal for asymmetrical chin), (21209)- Osteoplasty, facial bones; reduction, (31599)- Unlisted procedure, larynx, (40799)- Unlisted procedure, lips, (15776) Punch graft for hair transplant; more than 15 punch grafts, and (14020) - Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less.  The denial was reversed.

This patient had gender dysphoria and had taken hormone therapy since late-2016 including progesterone, estradiol, in addition to spironolactone.  This patient was living full time as a woman since then.  The patient had reports of feeling like a woman living in a man's skull, even though hormone replacement and removal of facial hair was done.  The patient was requesting facial feminization surgery (FFS), including reductions of forehead and contouring of the anterior frontal sinus wall, orbital repositioning, larynx work, hair work, and other surgical work so as to have a more feminine skull, face, and voice.  The insurer denied coverage for the requested surgeries stating that it was for cosmetic reasons.

This reviewer disagrees with the decision to deny coverage for the requested facial feminization surgery (FFS) as this was not considered cosmetic surgery, but rather medically necessary surgery for this patient to transition better into the female gender.  She had emotional discomfort due to feeling like a woman in a man's skull and face; it was causing distress. 

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 an accepted medical practice for the treatment of gender dysphoria and is recognized as an effective treatment of gender dysphoria with a triadic approach.  This triadic approach includes providing behavioral health treatment, hormone therapy, and surgeries as appropriate for male to female transgender people such as breasts via breast augmentation, vagina via vaginoplasty, and a female appearing face via facial feminization/reconstruction surgery.  

This patient had distress, worsened mental health issues, and worsened psychosocial functioning.  The patient still had many male facial features resulting in distress; therefore, facial feminization surgery was not considered cosmetic, but medical necessary to decrease distress and mental health issues, improve functioning and to feel more comfortable as a female.  The patient was also living as a female in a full time role since then.  As such, it was more than one year of living in the female role full time which also is a reported requirement prior to surgery. 

As a result, reverse the previous decision and approve the requested facial feminization surgery (FFS) for this patient.  The health care plan did not act reasonably or with sound medical judgment or in the best interests of the patient.  

The carrier's denial of coverage for facial feminization surgery (FFS) is reversed.  The medical necessity is substantiated.