Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria. 
Treatment: Facial feminization surgery. 

The insurer denied coverage for Facial feminization surgery. 

The denial is overturned. 
 
This is a request for facial feminization surgery due to gender dysphoria. 

According to the relevant surgical sections of World Professional Association for Transgender Health (WPATH) guidelines, 8th edition: 

13.6- We suggest health care professionals consider gender-affirming genital procedures for eligible* transgender and gender diverse adults seeking these interventions when there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated). 

13.7- We recommend surgeons consider gender-affirming surgical interventions for eligible* transgender and gender diverse adolescents when there is evidence a multidisciplinary approach that includes mental health and medical professionals has been involved in the decision-making process. 

In this case, there is evidence of a multidisciplinary approach that includes mental health and medical professionals has been involved in the decision-making process.  The patient's therapists and surgeon recommend facial feminization surgery as a key component of treatment for gender dysphoria. In addition, there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).  The patient has lived as a female for more than 4 years and has been on hormone therapy for at least one year. This patient has anxiety, depression and dysphoria that her mental health providers attribute directly to the incongruence of her facial appearance with her assigned sex. She is mistaken for male, which worsens her dysphoria. A study by Ainsworth et al found improved mental health functioning for transgender women following facial feminization surgery. Her condition represents a unique clinical situation in which facial feminization is indicated.  A systematic literature review on facial feminization by Morrison et al concluded: "based on these studies, it appears that facial feminization surgery (FFS) is highly efficacious and beneficial to patients.". Her condition represents a unique clinical situation in which facial feminization is indicated.  A systematic literature review on facial feminization by Morrison et al concluded: "based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients."  A recent study by Chou et al concluded: "FFS improves self-perceived and externally perceived facial femininity and reduces limitations in social and professional activities."  These procedures are necessary to treat the patient's unique clinical situation of disabling dysphoria related to the incongruence of her facial appearance as documented in the notes and letters from her treating mental health providers. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for facial feminization surgery (FFS) is substantiated.