Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gender dysphoria
Issue under review:  Sex reassignment facial feminization surgery

Determination:
The Sex reassignment facial feminization surgery is not medically necessary.

The patient is an adult male to female transgender woman. 

Based on review of the medical literature, despite the listed medical policy, facial feminization procedures that create and maintain gender specific characteristics as part of the overall desired gender reassignment services treatment plan may be considered medically necessary for the treatment of gender dysphoria.  Transgender patients are generally satisfied with the results of rhinoplasty and facial feminization surgery.  A systematic review of the facial feminization surgery literature included 15 published studies with a total of 1121 patients, demonstrating a high degree of satisfaction from patients.

However, review of the medical literature regarding facial feminization procedures demonstrates that while some facial feminization procedures addressing secondary sex characteristics can be effective in bringing the patient's face into increased congruence with their gender identity, there is no specific objective minimum degree of feminization or absolute requirement requiring a minimum feminine appearance in regards to medical necessity regarding facial feminization.  Therefore, actual documentation of the patient's gender dysphoria specific to the patient's facial appearance, as well as the patient's clinical treatment to address and manage gender dysphoria, is required to assess the degree of severity.  Photos may be helpful to correlate the patient's gender dysphoria associated with the patient's facial characteristics.

The requested procedures include burring of anterior wall of frontal bone; bilateral osteotomy of superolateral orbital rims; burring of nasion and nasofrontal region; rhinoplasty, and browlift.  The patient has previously undergone gender-affirming body procedures.

The patient's letter states that she remains with a "highly masculine appearance," preventing her from leaving her home, stating she has been verbally harassed.

Letters of affirmation from the patient's care providers state the patient has continued gender dysphoria due to her masculine appearance, resulting in verbal assault, and dysphoria when looking in a mirror.

In addition, documentation regarding lack of congruency regarding the patient's facial appearance includes clinical notes from the patient's treating provider.  However, the description of the patient's facial features are primarily descriptive and qualitative in nature.  The sole objective measurement includes a nasolabial angle listed at 92 degrees.

There is inadequate documentation regarding evidence of clinically significant distress in social, occupational, or other areas of functioning. Broad and generalized letters of attestation are all provided as part of the documentation in regards to the appeal for facial feminization surgery; however, no actual clinical notes at the time when the patient experienced gender dysphoria secondary to facial appearance are provided. 

While the patient is reported to have experienced multiple clinically significant functional issues secondary to distress regarding gender dysphoria, no time-specific documentation is provided regarding the clinical assessment and management that was undertaken to address this condition related to the patient's facial features that would have reasonably led to the patient this treatment. 

Photos were provided; however, they are not particularly demonstrable in regards to a "highly masculine appearance" and without correlative, time-specific clinical documentation in regards to the patient's gender dysphoria, the photographs alone do not substantiate the gender dysphoria described.

Therefore, facial feminization treatment is not medically necessary.