Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender dysphoria
Treatment: 15824 - Rhytidectomy; forehead, 15828 - Rhytidectomy; cheek, chin, and neck, 21122 - Genioplasty; sliding osteotomies, two or more osteotomies,
30410 - Rhinoplasty, primary; complete external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip, 67900 - Repair of brow ptosis
The insurer denied the 15824 - Rhytidectomy; forehead, 15828 - Rhytidectomy; cheek, chin, and neck, 21122 - Genioplasty; sliding osteotomies, two or more osteotomies, 30410 - Rhinoplasty, primary; complete external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip, 67900 - Repair of brow ptosis.
The denial is upheld. 

The patient is a male to female transgender individual who has been diagnosed with gender dysphoria.  The patient has been taking female hormone, and she has been maintained on hormone replacement therapy since.  The patient has undergone electrolysis to remove facial hair, but unfortunately is still bothered by significant dysphoria related to the masculine features of her face.

The patient has consulted with a plastic surgeon who recommended surgical facial feminization procedures in order to continue the gender confirmation process and address her concerns.  The patient desires a thyroid chondroplasty, with modification surgery liposuction of the waist rhinoplasty, facial bone reduction, rhytidectomy and blepharoplasty in order to continue the facial feminization confirmation.

No, the proposed treatment is not medically necessary and is cosmetic.

Based on review the clinical information provided and comparison with clinical practice standards and peer-reviewed literature established by the relevant medical community, the request for approval for the thyroid chondroplasty, with modification surgery liposuction of the waist rhinoplasty, facial bone reduction, rhytidectomy and blepharoplasty procedure for this patient may be denied as cosmetic procedures that are not considered to be medically necessary or indicated.  The clinical documentation provided clearly does not demonstrate that the patient suffers from any significant physical symptoms or functional impairment related the shape and appearance of the forehead, brow, jaw and trachea.  There are no functional or medically necessary physical indications for the requested facial surgeries.  There is no documentation of true physical symptoms or functional impairment related to the facial anatomy relative to the diagnosis of gender dysphoria.

In the context of the gender dysphoria, the clinical documentation does not demonstrate a significant enough masculine anatomy that could be considered a medically necessary indication for further feminization of the patient's appearance in this particular component of the anatomy.  Therefore, further modification of this anatomical component may be denied as primarily cosmetic enhancement and that is not considered medically necessary or indicated.

In addition, procedures associated with gender re-identification are an evolving field, and the definition of medical necessity for particular features and the changes that could be associated with that are still considered to be unproven in determining long-term health and welfare outcomes for prospective patients.

Therefore, the requested facial surgery procedure for feminization for this patient may be denied as unproven and cosmetic procedures that are not considered to be medically necessary based on clinical practice standards established by the relevant medical community.  This recommendation is consistent with the diagnosis of condition, as well as the type, frequency and duration of treatment given the clinical scenario presented.  This recommendation is in accordance with generally accepted standards of medical practice established by the relevant medical community and has not been given for the convenience of the patient, physician or other healthcare provider.