Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested authorization and coverage for facial feminization surgeries Findings:  The physician reviewer found that based on the entirety of the medical documentation provided for this review including review of the photographs, the requested services are not medically necessary and are not reconstructive in nature.  The patient is well documented to have gender dysphoria. Thus, facial feminization surgery and tracheal shave surgery can help to approximate a more feminine appearance.  However, there should be sufficient documentation that the patients current features are abnormal for a female. This has not been adequately documented for this case. There was not a detailed examination documented by the plastic surgeon supporting abnormal features of the patient. In addition, the photographs do not show evidence of a clearly masculine appearance of the brows, forehead, hairline, midface, and neck. Instead the photographs submitted appear to support a female appearance. Additionally, there is a lack of evidence to support a significantly prominent tracheal cartilage. The documentation provided indicates findings that are gender neutral in appearance, therefore, not atypical for a female appearance. The entire anterior hairline is not seen but appears only mildly receded.  There is no significant forehead prominence and brows appear without ptosis. The malar eminences appear normal. There is mild submental fullness and no significant tracheal prominence.  Thus, the patients facial appearance can be consistent in the spectrum of possible or typical female appearances. Overall, the clinical documentation does not support the medical necessity for the requested services. In general, the procedures do not specifically address gender related abnormalities. The documentation provided show findings consistent with a normal female face and neck.  As such, the requested procedures for this patient should be considered treatment of normal structures for her age and gender. For these reasons, the facial feminization surgeries  are not medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, the submitted documentation does not demonstrate that the patients condition constitutes an abnormal body structure. The medical documentation and review of the photographs appear to support a patient with an appearance that is not necessarily gender specific and appears female in appearance. As stated and reasoned above, the requested facial feminization surgeries are more consistent with aesthetic improvement, addressing appearance concerns, and not specific to gender related abnormalities. Thus, this patients facial presentation does not constitute an abnormal body structure. Therefore, the requested services are not reconstructive in natureFinal Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.