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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consultation with a dermatologist regarding laser removal of facial hair. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees gender dysphoria. A review of the records indicates that the enrollee has been diagnosed with gender dysphoria of adulthood and pectus excavatum. A letter from the provider reported the enrollee has been taking feminizing hormone therapy since July of 2017, and in addition to laser hair removal, the enrollee is planning other procedures. The provider reported the enrollee experiences discomfort and distress related to the prominence of their facial hair, as that aspect of their body is perceived as a strong masculine feature. The enrollee attempted to remove facial hair by going to a cosmetologist but was not successful as the procedure caused a lot of bleeding. The enrollee reported they are not comfortable with their face and feel like its holding them back from living a normal life. The provider reported the enrollee is psychologically stable for this procedure. Facial hair removal via laser would provide reconstructive surgical services for an abnormality because of the disorder of gender dysphoria. The outcome of the procedure would be enhancement of psychological and social functioning. The patient has a documented history of gender dysphoria, has been on cross gender hormone therapy and the mental health evaluation documents exacerbation of gender dysphoria symptoms due to the presence of facial hair. The 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 medical necessity and the classification of laser hair removal as medically necessary WPATH states that, In addition to hormonal balancing, medically necessary gender affirming/confirming surgical procedures are described in section XI of the standards of care (SOC). These procedures include 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. The medical procedures attendant to gender affirming/confirming surgeries are not cosmetic or elective or for the mere convenience of the patient. The Transgender Medicine Model NCD Working Group, Transgender Law Center in their review of evidence for gender confirming surgeries state that, Other 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 removalThese procedures are not cosmetic, but rather serve a primarily reconstructive purpose by allowing transgender women whose overall physical appearance otherwise prevents them from being perceived as female. Based on the documented history of gender dysphoria and evidence of the medical necessity of dermatology consultation for laser facial hair removal, the requested consultation with a dermatologist regarding laser removal of facial hair is determined to be medically necessary. Final Result: The reviewer determined that the requested service is 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, with subspecialty certification in psychosomatic medicine 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.