Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Male to female transgender.
Treatment: Facial Feminization Surgery (21139, 15824, 67900, 21209, 21122, 21198, 21194).
The insurer denied the Facial Feminization Surgery (21139, 15824, 67900, 21209, 21122, 21198, 21194).
The denial is overturned.

This is a male to female transgender. She has been on hormone therapy for several years. Despite hormone therapy, she continued to have masculine facial features. Her mental health professionals documented worsening dysphoria due to her masculine facial features. She was frequently mistaken for a male. Facial feminization was recommended to make her facial appearance more congruent with her new female gender.

Yes, the proposed treatment is medically necessary.
All of the procedures should be certified. According to the World Professional Association for Transgender Health (WPATH) guidelines: "Other surgeries for assisting in body feminization include reduction thyroid chondroplasty (reduction of the Adam's apple), voice modification surgery, suction-assisted lipoplasty (contour modeling) of the waist, rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid). Other surgeries for assisting in body masculinization include liposuction, lipofilling, and pectoral implants. Voice surgery to obtain a deeper voice is rare but may be recommended in some cases, such as when hormone therapy has been ineffective.  Although these surgeries do not require referral by mental health professionals, such professionals can play an important role in assisting clients in making a fully informed decision about the timing and implications of such procedures in the context of the social transition. Although most of these procedures are generally labeled 'purely aesthetic,' these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient's condition and life situation. This ambiguity reflects reality in clinical situations and allows for individual decisions as to the need and desirability of these procedures." 

This patient has anxiety, depression and dysphoria that her mental health providers attribute directly to the incongruence of her facial appearance with her assigned sex. She is frequently mistaken for male, which worsens her dysphoria.   A study by Ainsworth et al found improved mental health functioning for transgender women following facial feminization surgery.  The patient's condition represents a unique clinical situation in which facial feminization is indicated.  A systematic literature review on facial feminization by Morrison et al concluded: "based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients.". 

These procedures are necessary to treat the patient's unique clinical situation of disabling dysphoria related to the incongruence of her facial appearance as documented in the notes and letters from her treating mental health providers.

Facial feminization for this patient is an essential treatment for the management of her diagnosis of gender dysphoria.