Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria

Treatment: Genioplasty (code 21121), rhinoplasty (code 30410), and removal of skin lesion (code 11400)

The insurer denied coverage for genioplasty (code 21121), rhinoplasty (code 30410), and removal of skin lesion (code 11400)

The denial is overturned

According to the denial rationale from the health plan in a denial letter dated, they stated that: 1) Medical studies haven't proven that this procedure significantly reduces or resolves gender dysphoria and 2) The procedure would not correct, repair, or improve function of an abnormal part of the body.  These statements are not correct.
 
According to the relevant surgical sections of the World Professional Association for Transgender Health (WPATH) guidelines, 8th edition:

-> 13.6- We suggest health care professionals consider gender-affirming genital procedures for eligible transgender and gender diverse adults seeking these interventions when there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).
-> 13.7- We recommend surgeons consider gender-affirming surgical interventions for eligible transgender and gender diverse adolescents when there is evidence a multidisciplinary approach that includes mental health and medical professionals has been involved in the decision-making process.

In this case, there is evidence of a multidisciplinary approach that includes mental health and medical professionals has been involved in the decision-making process. The patient's therapists and surgeon recommend facial feminization surgery (FFS) as a key component of treatment for gender dysphoria. In addition, there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).  The patient has lived as a female and has been on hormone therapy since 2021. This patient has anxiety, depression and dysphoria that their mental health providers attribute directly to the incongruence of their facial appearance with their assigned sex. A study by Ainsworth et al found improved mental health functioning for transgender women following facial feminization surgery. Their 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." The patient's condition represents a unique clinical situation in which facial feminization is indicated.  A prospective, international, multicenter, cohort study by Morrison et al concluded: "Facial feminization achieved improved quality of life, feminized cephalometries, feminine gender appearance, good overall aesthetics, and high satisfaction that were present at 1 month and stable at more than 6 months."  A recent study by Chou et al concluded: "FFS improves self-perceived and externally perceived facial femininity and reduces limitations in social and professional activities."  These procedures are necessary to treat the patient's unique clinical situation of disabling dysphoria related to the incongruence of their facial appearance as documented in the notes and letters from their treating mental health providers.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for genioplasty (code 21121), rhinoplasty (code 30410), and removal of skin lesion (code 11400) is substantiated.