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

The patient had a history of gender dysphoria and has been treated with cross-gender hormone therapy since 2016. The submitted documentation indicates that patients facial hair limits her ability to be perceived and negates her gender identity. The patient reports being constantly mis-gendered due to the presence of facial hair, which exacerbates her symptoms of gender dysphoria. The documentation also indicates the patient has had both electrolysis and laser treatment in the past without side effects. A referral was made to dermatology for laser hair removal for gender dysphoria. A dermatology consultation on 11/2/18 revealed the patient was assessed for laser hair removal as part of treatment for gender dysphoria. The patient would like the facial hair treated; otherwise, she otherwise has to shave daily. This patient has a documented history of gender dysphoria treated with cross-gender hormone therapy. The patients mental health evaluation documents exacerbation of gender dysphoria symptoms due to the presence of facial hair. Guidelines for the medical necessity of facial feminization surgery (FFS) exist in two reviews from World Professional Association for Transgender Health (WPATH) and the Transgender Law Center. On the matter of classification of laser hair removal, the WPATH states that in addition to hormonal balancing, medically necessary gender affirming/confirming surgical proceduresinclude complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, scrotoplasty, and penile and testicular prostheses, as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. Researchers reported that on review of evidence for gender confirming surgeries, additional surgeries or procedures that may be necessary to resolve gender dysphoria and allow transgender women to navigate the world as women include facial and body hair removal. The authors noted that these procedures serve a primarily reconstructive purpose by allowing transgender women whose overall physical appearance otherwise prevents them from being perceived as female. Based on this patients documented history of gender dysphoria, the requested facial laser hair removal is supported as medically necessary. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in Psychiatry 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.